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Pain Report #11- Pain Management for the Elderly

The Older Patient in Pain

Pain is a common complaint among elderly people. For ambulatory care visits, pain related problems are more common than any other complaint. The intensity of pain often correlates with the severity of injury and indicates urgency for treatment. Over time, unrelieved pain, pain that persists, or pain out of proportion to tissue damage, often results in substantial disability and psychological distress.

The prevalence of pain is high in the elderly population. Epidemiology studies of pain in general populations have suffered from the lack of standard definitions for what might be considered “significant” pain. Nonetheless, studies have suggested that the prevalence of pain in community-dwelling older persons may be as high as 25% to 56%. Sources of pain also vary from study to study. Prevalence of back pain has been reported from 21% to 49.5%; joint pain 20.5% to 71%; and headache 1.2% to 50% in persons over the age of 65 years. In general, the most common causes of pain in elderly persons are probably related to musculoskeletal disorders, such as back pain and arthritis. Neuralgia is also common stemming from diseases, such as diabetes and herpes zoster; and from trauma, such as surgery, amputation, and other nerve injuries. Nighttime leg pain (e.g. cramps, restless legs) is also common, as is caludication. Cancer, although not as common as arthritis, is a cause of severe pain. The distress of cancer pain has brought attention to the obligation clinicians have to provide effective pain management, especially near the end of life. Pain is also common in nursing homes. It has been suggested that 45% to 80% of nursing home residents may have substantial pain. Many of these patients have multiple pain complaints and multiple potential sources of pain.

Pain is associated with a number of negative outcomes in elderly people. Depression, decreased socialization, sleep disturbance, falls, adverse drug events, slow rehabilitation, and increased health care utilization/costs have all been associated with either the presence of pain or its treatment in older people. Older patients rely heavily on family and other caregivers near the end of life. For these patients and their caregivers pain can be especially distressing. Caregiver strain and caregiver attitudes can have substantial impact on pain.

The approach to pain management is different in elderly versus younger persons. Older persons may under-report pain. They often present with concurrent illnesses and multiple problems, which makes pain evaluation and treatment more difficult. Elderly persons have a higher incidence of side effects to medications and higher potential for complications and adverse events related to many treatment procedures. Despite these challenges, pain can be effectively managed in most elderly patients. Moreover, clinicians have an ethical and moral obligation to prevent needless suffering and provide effective pain relief, especially for those near the end of life.

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