View Entire Collection
By Clinical Topic
Diabetes – Summer 2012
Future of Nursing Initiative
Heart Failure - Fall 2011
Influenza - Winter 2011
Nursing Ethics - Fall 2011
Trauma - Fall 2010
Traumatic Brain Injury - Fall 2010
Fluids & Electrolytes
IF YOUR PATIENT is age 65 or older and experiencing pain, treatment options may be more limited than for a younger adult because age-related physiologic changes affecting hepatic and renal function influence the safety and efficacy of many analgesics. Lifelong attitudes towards pain and pain medications can also be a barrier to effective pain management for older patients who fear addiction or adverse reactions such as sedation. In addition, some healthcare professionals have lingering misconceptions about managing pain in older patients-mistakenly believing, for example, that opioids are rarely appropriate for older patients.
Pain isn't a normal part of the aging process, yet research shows that it's all too common among older adults.1,2 This article will describe how to lower the barriers to effective pain control in older patients and provide practical tips for helping them receive the full benefit from pharmacologic and nonpharmacologic therapies. First, however, some myths about pain in older adults must be dispelled.
One of the myths standing in the way of effective pain control in older patients is the notion that pain is a natural consequence of aging. Many older patients erroneously believe that pain is just part of growing old.2,3 This acceptance of pain as a part of life can diminish a patient's quality of life by limiting the ability to socialize, provide self-care, and engage in meaningful activities. Providing adequate pain management can improve self-esteem and the ability to enjoy life.
But before you can treat pain you need to know about it, and older patients may not be comfortable reporting pain to you for several reasons. Those who've been living with pain for many years may believe it's just part of life and not worth mentioning to you. They may also want you to see them as "good" patients who don't bother you with trivial complaints.
Some healthcare professionals also have mistaken ideas about pain management that can stand in the way of effective treatment. One is the belief that older patients don't feel pain as acutely as younger adults. In fact, older patients can experience a pain stimulus in the same way a younger patient can,1,4 but transmission of the pain impulse by the nervous system may be altered by concurrent chronic disorders such as diabetes, neuropathies, vascular disease, or arthritis. In patients with nerve damage, pain won't be transmitted the same way it is in younger, healthier patients.
Another myth that healthcare professionals may believe is that older patients can't reliably report pain. But research shows that most older patients can do so using the simple numeric rating scale (NRS). Easy to use, the NRS lets the patient rate pain on a scale from 0 (no pain) to 10 (worst pain possible).
If a patient has hearing and vision impairments, make sure that all assistive devices, such as hearing aids and glasses, are in place before performing a pain assessment. Some older patients who seem unable to report their pain are more than able to describe it when they're wearing their glasses and hearing aids.
An older patient may experience pain from various sources: osteoarthritis, rheumatoid arthritis, neuropathies, or vertebral disk degeneration to name a few. (See Common sources of pain in older adults.) The most common pain complaints from older patients are articular joint pain and foot or leg pain, which become more likely as a patient ages. Other types of pain seem to decrease with age, such as headache, abdominal pain, and chest pain.5
Typically, an older patient has more pain with activity, such as walking or climbing stairs. If you can help decrease pain by even 25%, functionality may improve by as much as 50%.3
By 2030, an estimated 20% of the U.S. population will be over age 65.6 Not only will many more older adults be entering the healthcare system, but these older patients will also have a longer life expectancy than previous generations.
According to one study, about 80% of residents in long-term-care facilities may experience chronic, daily pain.2 In another study examining the types of painful conditions experienced by residents of long-term-care facilities, the incidence of painful conditions was found to be similar in patients with and without dementia.5 Researching pain experiences in long-term-care facilities is complicated by the number of nonverbal residents who can't self-report pain.
For community dwelling older adults, the prevalence of pain is somewhat lower: an estimated 25% to 50% of the population. Cancer, one of the leading causes of death in older patients, is a significant source of pain.2
According to the American Pain Society, 20% to 75% of patients with cancer are experiencing pain at the time of diagnosis, and 14% to 100% of patients with cancer report pain after diagnosis. Along with cancer symptoms, many patients report other sources of persistent pain, such as low back pain that increases at night and doesn't respond to the usual measures.7
Ethnicity and financial status also affect pain management in older patients. Minority patients face a higher risk of untreated or undertreated pain. In a study where minority patients were asked about pain, 28% of community dwelling minority patients reported daily pain.8 Some predictors of severe pain for older adults include being a Medicaid recipient, two or more comorbidities, low educational level, and psychological distress.9
In one review of medication use, only one in five older patients who were experiencing pain used pain medication within a 1-week assessment period. Contributing factors to suboptimal pain management were undertreatment by prescribers, financial difficulties/cost of medications, and reluctance to take medications.9
Prescribers sometimes undertreat pain for fear of adverse drug reactions, but they should realize that undertreated or untreated pain can also have many damaging effects, such as depression and anxiety.3 Some of the anxiety stems from the patient's fear of losing independence when self-care is so difficult. Patients who are in pain may also lack the energy to socialize, and this can be exacerbated by sleep disturbances from pain at night. Loss of ability to maintain normal function can lead to increased utilization of healthcare services and other costs that many patients can ill afford.
When working with older patients, be aware that they may be afraid to report pain for any or all of the reasons discussed above. A careful nursing assessment of all the factors that influence the way patients report pain will help you determine which therapies are most likely to help your patient. This takes time and may require a more comprehensive approach to information gathering than might be needed with a younger patient.
Take a thorough health history and perform medication reconciliation. Evaluate mental, psychological, and emotional function, coping mechanisms, pain beliefs, and family and social supports.7,10
Also perform a thorough physical assessment, including functional abilities (such as the ability to ambulate and how far, balance, and the ability to perform self-care), as well as disabilities and baseline vital signs.
After performing a physical assessment, initiate a frank discussion about any pain problems the patient may be experiencing. The patient's self-report of pain is the most reliable indicator-far more reliable than your physical findings or observations of behavior. Most older patients, even those with cognitive impairment, can reliably self-report pain using the NRS or similar pain rating tool. Many pain intensity rating tools are available, but some are better suited for certain patients than others.
Most cognitively intact older patients and patients with mild to moderate cognitive impairment can use the NRS pain intensity scale to self-report pain. Better success has been reported with the use of an NRS scale that's vertically oriented. The verbal descriptor scale (VDS), which uses words such as mild, moderate, and severe to describe pain, may be useful for patients who have mild to moderate cognitive impairment.5 The vertically oriented thermometer scale shown in the illustration blends the NRS and VDS.
Older patients with cognitive impairment don't lose the ability to feel pain, but they may have trouble conveying the meaning of the pain. A tool that incorporates descriptive words may help patients with mild to moderate cognitive impairment to describe their pain to you.
In a study of patients with acute surgical pain, researchers compared the NRS, VDS, the McGill Pain Questionnaire (a multidimensional pain scale), and some different configurations of scales in younger and older patients. The patients were all receiving patient-controlled analgesia to manage pain. In both age-groups, the NRS was the pain scale selected as easiest to use, with the lowest error rate and highest validity scores. The VDS received the second-best ratings. The most important finding was the lack of age differentiation in scoring. Older adults liked it as well as the younger patients and found it easy to use.11
Older nonverbal patients, especially those with dementia, are vulnerable to being overlooked for pain assessment despite having many potential sources of pain. Although self-report is the gold standard of pain assessment, these patients can't verbally communicate their feelings. New behavioral pain scales are being developed to help clinicians assess pain in patients who may have a history of stroke, aphasia, or dementia, and in those who are critically ill and endotracheally intubated. Guidelines for assessing a nonverbal patient include the following.
* Always attempt to obtain a self-report whenever possible.
* Ask family and caregivers about baseline performance. For example, does a patient who normally bathes herself stop doing so when she's in pain? Also ask about usual pain indicators, such as frowning when in pain.
* Use a behavioral pain scale, as discussed below, to document pain. All caregivers should use the same scale consistently.
* Choose appropriate outcomes that indicate pain relief; for example, patient is able to participate in activities such as sitting with other patients in a common room.
Changes in vital signs and other physiologic indicators aren't reliable indicators of pain, but research has identified certain behaviors that represent pain in nonverbal patients. These have been identified in studies that compared pain ratings by verbal and cognitively intact patients with similar patients who were nonverbal.12,13 From these behaviors the Checklist of Nonverbal Pain Indicators (CNPI) was developed. Additional pain behaviors identified by the American Geriatrics Society (AGS) have been added to the list of identified pain behaviors.2 Behaviors from the CNPI that have been identified as indicating pain include:
* nonverbal vocal complaints (sighs, gasps, moans, groans, cries)
* facial grimacing
* bracing (clutching or holding onto furniture, equipment, or affected area during movement)
* rubbing (massaging affected area)
* verbal vocal complaints, such as "ouch" or "stop."
Pain assessment tools using patient behaviors are the newest additions to the pain assessment toolbox and are still works in progress. The Pain Assessment in Advanced Dementia (PAINAD) scale is gaining popularity with practitioners because of its quick and easy-to-use format. This tool assesses breathing independent of vocalization, negative vocalization, facial expression, body language, and consolability. Each behavior is scored with a numeric rating. The higher the score, the more severe the pain. For example, a facial expression score of 0 indicates smiling or a neutral expression, 1 indicates a frightened or frowning expression, and 2 indicates grimacing.
Another tool for assessing pain in nonverbal older patients, the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC), is a 60-item observational tool that's also quick to use. It covers the elements of nonverbal pain assessment that are included in the AGS listing of pain behaviors.2,5
Although available tools to assess nonverbal pain aren't fully developed, they can help you accurately assess a patient's pain if you and other caregivers use the same tool frequently and consistently. With ongoing research and refinement, these tools will continue to evolve into better and even more reliable resources.
Effective pain management in older adults typically requires a combination of pharmacologic and nonpharmacologic therapies. In some cases, an invasive procedure may be indicated. Frequently reevaluate the patient's response to therapy for clues about which treatments work best and tailor the plan of care as needed.
When planning care, avoid polypharmacy whenever possible. Ask patients or a family member to bring in all medications they're taking or have taken recently in the original packaging. Request that along with prescription medications, they should include over-the-counter medications, herbal products, vitamins, inhalers, antacids, and eyedrops. With this "brown bag" session, you may uncover outdated medications and multiple prescribers who aren't aware of medications prescribed by other healthcare providers. Look for potential drug-drug interactions or drugs that cause sedation.
Besides current medications, note those that have been discontinued, and ask why. Some patients discontinue medications on their own if adverse reactions are too troublesome. Others may take more medication than indicated because of forgetfulness or in attempts to manage their pain better. Looking at how much medication has been taken will help you assess how well the pain regimen is working and how well the patient understands the treatment plan.
Be sure to ask about other substances, such as alcohol, that patients may use to help control pain. If pain medication doesn't decrease pain to an acceptable level, some patients add a daily dose of alcohol to the regimen. Explore this possibility in a nonjudgmental way, focusing on the risk of oversedation and other potential dangers of mixing drugs and alcohol. If your patient is using alcohol for adjunct pain relief, alert the healthcare provider to the need for a more effective pain control regimen.
Possible pain medication options for treating pain can be listed according to the World Health Organization (WHO) Three-Step Ladder, which applies generally to all adult patients. (See Climbing the WHO pain management ladder.)
Because of risks associated with nonsteroidal anti-inflammatory drugs (NSAIDs), new guidelines from the AGS recommend considering opioids instead for patients with moderate to severe pain or diminished quality of life due to pain.15 "Starting low and going slow" is a good approach to using opioid medications. As a general rule, beginning opioid doses should be 25% to 50% lower than the usual adult dose to decrease the potential for oversedation. With continued opioid use, patients develop tolerance to sedation and other adverse reactions with the exception of constipation.
After a patient starts on a small dose of an opioid, assess frequently for pain relief and adverse reactions. Ask family members to observe the patient's response and watch for adverse reactions such as sedation. Depending on the response to treatment, the prescriber may want to change the dosage or the opioid to achieve the best pain relief with minimal adverse reactions.
Besides the primary medication for pain, adjuvant medications such as antidepressants or antiepileptic drugs can help reduce chronic pain, particularly neuropathic pain. However, the tricyclic antidepressants amitriptyline, nortriptyline, and desipramine aren't recommended for older patients because they may cause unacceptable adverse reactions such as orthostatic hypotension, increasing the risk of falls.2,6
Although NSAIDs have long been a standard for pain relief in older patients, newer research from the FDA and the American Heart Association indicate that all NSAIDs, including the selective COX-2 inhibitors such as celecoxib, have the potential for increased cardiovascular risk, stroke, and myocardial infarction. Gastrointestinal (GI) bleeding continues to be a risk with NSAIDs. The bleeding risk increases several folds if the patient also takes aspirin for cardiovascular prophylaxis.16
In addition to all the above considerations, new recommendations from the AGS indicate that all NSAIDs-both selective and nonselective COX inhibitors-should be considered for use only rarely in highly selected individuals.15 Patients who meet the criteria for use of NSAIDs and for whom they are prescribed should be screened regularly for GI bleeding, renal toxicity, hypertension, heart failure, and other drug-drug and drug-disease interactions. Any older patient who's taking an NSAID should be also taking a proton pump inhibitor or misoprostol for GI protection.
A patient with mild pain may respond to acetaminophen, but this drug must also be used with caution in an older adult. The maximum total daily dose for adults in general is 4 g/day, but the total daily dose should include all the "hidden" acetaminophen found in combination products such as Tylenol#3, Vicodin, or Percocet. If the patient has a history of alcohol abuse or hepatic or renal impairment, the maximum daily dose should be decreased by 50% to 75% or not used at all. The AGS now recommends that liver failure be an absolute contraindication for acetaminophen use; relative contraindications and cautions include hepatic insufficiency and alcohol use or abuse.2,15
For general recommendations for using analgesics in older adults, see Safety Tips for Medication Administration.
Using topical medication for pain is an option that older patients are open to discussing. Analgesic balms or topical medications such as diclofenac (Flector), a topical analgesic patch, or a transdermal lidocaine patch (Lidoderm) can provide some level of pain relief while not affecting the GI system.
The diclofenac patch is the newest addition to topical pain control. Its "put the patch where the pain is" approach can help with minor musculoskeletal pain without systemic effects.
The lidocaine patch can provide pain relief for patients who can point to the painful area to indicate the pain's exact location.16 This is a safer option than opioid transdermal medications, which have the potential for producing systemic effects and adverse reactions such as sedation. These should be reserved for oncology patients and others on chronic opioid therapy who are opioid tolerant.
Nonpharmacologic methods such as heat and cold applications are effective, low-risk options for older patients. Other effective options include relaxation and distraction techniques (such as music, meditation, imagery, and humor), acupuncture, exercise programs, and cognitive behavioral approaches to increase coping skills.3
Managing pain in an older adult patient may require extra time, patience, and a trial-and-error approach. For best results, try to put the patient at ease and create a climate of trust and collaboration. Listen to what the patient tells you about medication and lifestyle preferences. Take these preferences into account when you develop a plan of care so the patient will be more likely to follow it at home.
Discuss the plan of care in a quiet room. Turn off the television and minimize interruptions. Make sure the patient is wearing any assistive devices, such as glasses or a hearing aid.
Teach the patient about all the medications currently prescribed, including medication name, dose, time to take it, any special considerations (such as taking it with meals), intended effects and possible adverse reactions, and whom to call with questions. This helps prevent the "little blue pill" syndrome, where the patient identifies medication only by pill size and color and doesn't know its name, dose, or indication. Provide written instructions for reference at home. For easy reading, these should be printed in large font on nonglossy paper on a background that provides a good contrast between the text color and background.
To help the patient take medication as prescribed, suggest using a device such as a pillbox, which can help prevent unintentional duplicate medication administration. If appropriate, a relative or friend could keep it filled.
Many patients stop taking their drugs (particularly opioids) because of adverse reactions, so specifically question your patient about any problems. Constipation is a predictable adverse reaction to opioids, so all patients taking an opioid should be started on a laxative regimen consisting of a stool softener and mild laxative. Encourage your patient to communicate problems to you or the healthcare provider so you can find solutions.
Involve the patient's family and significant others in your patient's plan of care. Those who know her well may be the first to detect drug reactions or increasing pain. Teach them to watch for indicators that the patient isn't tolerating the medication well, such as changes in mental status, excessive sleepiness, agitation, sleep disturbances, and delirium.
Pain isn't a normal part of aging. Treating pain effectively is just as important for older adults as for younger patients. Using a multimodal approach with medications, interventional options, and nonpharmacologic techniques can help manage pain and improve your patient's quality of life.
* peripheral vascular disease
* poststroke syndrome
* pressure ulcers
* oral/dental problems
* degenerative joint disease
* rheumatoid arthritis
* chronic cancer pain or treatment-related pain syndromes such as chemotherapy-induced peripheral neuropathy
WHO promotes a stepwise approach to managing pain based on pain intensity.14 You can use this as a framework to match the patient's pain intensity to a suitable medication. Keep in mind, however, that the latest guidelines from the AGS recommend avoiding prolonged use of NSAIDs in older adults because the risks outweigh the benefits.15
Step 1. Mild pain, pain intensity level 1-3 (based on a standard 0-to-10 NRS): acetaminophen, NSAIDs
Step 2. Mild to moderate pain, pain intensity level 4-6: combination of medications with acetaminophen and oxycodone or hydrocodone, or oxycodone (short acting or extended release)
Step 3. Moderate to severe pain, pain intensity level 7-10: opioid medications such as morphine, hydromorphone, fentanyl, methadone.
Follow these guidelines to help your older patient get maximum pain relief with minimal risk.
* Administer shorter acting medication at the onset of therapy to minimize adverse reactions.
* When pain is present all day, give medication on an around-the-clock schedule (rather than as needed) for more consistent pain relief and a lower risk of breakthrough pain.
* Monitor a patient starting opioid therapy closely, at least daily, for pain relief and adverse reactions. Remember that age-related changes in metabolism and renal and hepatic function can affect drug metabolism and elimination and raise the risk of adverse reactions.
* Because of adverse reactions and toxic metabolites, avoid giving these medications to older patients: meperidine, propoxyphene, pentazocine, indomethacin, and amitriptyline.3
1. Huffman JC, Kunik ME. Assessment and understanding of pain in patients with dementia. Gerontologist. 2000;40(5):574-581. [Context Link]
2. American Geriatrics Society. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50:S205-S224. [Context Link]
3. McLennon SM. Persistent Pain Management. Iowa City: University of Iowa Gerontological Nursing Interventions Research Center; 2005. http://www.guideline.gov/summary/summary.aspx?doc_id=8627/. [Context Link]
4. D'Arcy Y. Pain in the older adult. Nurse Pract. 2008;33(3):19-24. [Context Link]
5. Hadjistavropoulos T, Fine PG. Chronic pain in older persons: prevalence, assessment and management. Rev Clin Gerontol. 2006;16:231-241. [Context Link]
6. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia: Lippincott Williams & Wilkins; 2007. [Context Link]
7. Guideline for the Management of Cancer Pain in Adults and Children. Glenview, IL: American Pain Society; 2005. http://www.ampainsoc.org/pub/cancer.htm. [Context Link]
8. Reyes-Gibby CC, Aday LA, Todd KH, Cleeland CS, Anderson KO. Pain in aging community dwelling adults in the United States: non-Hispanic whites, non-Hispanic blacks, and Hispanics. J Pain. 2007;8(1):75-84. [Context Link]
9. Bruckenthal P, D'Arcy Y. Assessment and management of pain in older adults: a review of the basics. Topics Adv Pract Nurs eJournal. 2007;7(1). [Context Link]
10. Hadjistavropoulos T, Herr K, Turk DC, et al. An interdisciplinary expert consensus statement on the assessment of pain in older persons. Clin J Pain. 2007;23(suppl. 1):S1-S43. [Context Link]
11. Gagliese L, Weizblit N. Ellis W. Chan VW. The measurement of postoperative pain: a comparison of intensity scales in younger and older surgical patients. Pain. 2005;117(3):412-420. [Context Link]
12. Feldt KS, Ryden MB, Miles S. Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip fractures. J Am Geriatr Soc. 1998;46(9):1079-1085. [Context Link]
13. Feldt KS. The checklist of non-verbal pain indicators (CNPI). Pain Manag Nurs. 2000;1(1):13-21. [Context Link]
14. World Health Organization. WHO's Pain Relief Ladder. http://www.who.int/cancer/palliative/painladder/en/. [Context Link]
15. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331-1346. [Context Link]
16. D'Arcy Y. Pain Management: Evidence-Based Tools and Techniques for Nursing Professionals. Marblehead, MA: HcPro, Inc.; 2007. [Context Link]
Back to Top