Managing chronic pain in the elderly

A complex and unpleasant sensory and emotional experience, pain is a symptom. It’s never normal. When pain lasts beyond the time of healing or continues 3 months or longer, it’s classified as chronic.

Unlike graying hair and wrinkled skin, chronic pain is not part of the normal aging process. While chronic pain has many possible causes, each type of pain has its own unique quality. (See the box below.)

Causes of chronic pain
Advanced age increases the risk of certain health disorders that can cause chronic pain. Conditions that can lead to chronic pain in older adults include musculoskeletal disorders, such as arthritis and osteoporosis, peripheral vascular disorders, and neuropathic pain (including postherpetic neuralgia).

For older adults who live independently, chronic pain can have devastating and widespread effects, threatening the quality of life, imposing steep economic and social costs, and leading to personal strain. Yet many older adults don’t report their pain to healthcare providers or discuss its impact. The reason: They fear invasive tests, hospitalization, loss of independence, or the need to take additional medications. This may result in underdiagnosis and inadequate treatment, which can further diminish the quality of life.

Chronic pain is, and will continue to be, a concern as the elderly population grows. In 2006, Americans older than age 65 numbered about 36 million (12.4% of the population). By 2030, this group will number 70 million (about 20%).

How pain disrupts quality of life

Chronic pain has been linked to sleep disturbances, depression, reduced social activity, and poor physical functioning. These problems can make an older adult more dependent on others for activities of daily living (ADLs) and may lead to social isolation and increased healthcare costs. What’s more, pain is commonly perceived as a threat and influences the older adult’s coping process.

Effects of pain on sleep

Chronic pain can disturb sleep in several ways. Falling asleep may be difficult for elderly persons who have endured the stress of chronic pain during the day. Quality of sleep may suffer due to frequent awakenings, as turning in bed may cause pain. Also, sleep deprivation and altered sleep quality can reduce the pain threshold. Thus, a vicious cycle—decreased sleep quality, lowered pain threshold, and reduced ability to cope with chronic pain—arises.


Depression and distress

Many older adults with chronic pain experience depression, which can hinder their ability to cope with pain. Additionally, pain may worsen cognitive dysfunction and malnutrition.

One study found that along with financial hardship and certain other factors, chronic pain contributed to distress and depression among community-dwelling elderly adults. The chronic pain of arthritis interfered with daily activities, making it hard for them to carry out ADLs, which in turn led to distress. In this study, chronic pain was linked directly to depression. The author suggested that although people might be able adapt to chronic pain and may not appear to be distressed on a daily basis, pain may have long-term effects manifesting in depression.

A recent study of older women with chronic pain surveyed three groups using the Pain Disability Inventory and additional instruments. Women in two of the groups had greater daytime dysfunction due to chronic pain than those in the other group, along with significantly higher ratings on the Beck Depression Inventory. These groups rated their social functioning, general health, physical functioning, and mental health significantly lower than women in the first group.

Assessment

Assessing chronic pain in older adults can be challenging because this population tends to underreport pain. Also, unlike patients with acute pain, those with chronic pain generally don’t manifest autonomic pain responses, such as increased heart rate and respirations.

Using a pain scale is helpful when assessing an older adult for pain. Otherwise, your patient may respond to a question about pain with a vague statement such as, “No worse than usual” or “It’s the same old pain” or “It’s a part of getting old.” Encourage the patient to keep a pain diary to help identify events that precipitate or increase pain. A pain diary also can yield clues to the occurrence of breakthrough pain. If assessment findings suggest your patient has chronic pain, try to find out whether and to what extent the pain has affected quality of life.

Plan of care

Caregivers must develop a plan to address the patient’s chronic pain. The plan should identify the patient’s comfort-function goal—the level of pain management needed to reach the desired functional ability. Establishing a realistic comfort-function goal gives the patient direct input into her pain management plan and its implementation. It also holds both the healthcare team and patient accountable for providing adequate pain relief.

Some older adults may need help in establishing realistic goals. Inquire about pain-related functional limitations that the patient finds distressing.

Pharmacologic pain management

Many pharmacologic pain-management options exist. However, physiologic changes in the aging body and coexisting health conditions can present a challenge to pharmacologic measures in the elderly. Such physiologic changes alter drugs’ pharmacokinetics and pharmacodynamics. For this reason and others, some medications are inappropriate for managing pain in older adults. The Beers criteria lists potentially inappropriate medications for use in older adults. It groups these drugs in two categories:

  • drugs or drug classes that generally should be avoided in persons age 65 or older because they are ineffective or pose unnecessarily high risk and a safer alternative is available
  • drugs that shouldn’t be used in older adults who have specific medical conditions.

For many patients, the pain-management plan may need to include nonpharmacologic methods (discussed below) as well as pharmacologic methods.

Promoting compliance with drug therapy

Compliance with drug therapy can pose a challenge. Many elderly adults mistakenly think they should take analgesics only when pain becomes unbearable; some fear they’ll become addicted to them. Emphasize the importance of taking pain medication to “keep ahead” of the pain, rather than waiting until the pain becomes unbearable.

Some older adults may avoid pain medication because of constipation and other adverse effects. If fear of constipation stops your patient from taking needed medication, educate her about helpful dietary changes, such as drinking more fluids and eating more fiber-rich foods.

Nonpharmacologic pain management

Many older adults are more open to nonpharmacologic approaches to managing pain. As appropriate, teach patients about exercise, relaxation, acupuncture, guided imagery, music therapy, and spiritual interventions. Other nonpharmacologic options include:

  • biofeedback
  • distraction (such as watching television or talking on the telephone)
  • humor
  • repositioning.

In some situations, heat or cold application or massage may be appropriate. But caution older adults who have neuropathic pain or ischemic pain stemming from peripheral arterial disease not to use heat or cold, as this may cause altered sensation in the extremities and tissue damage. Encourage patients with joint pain to stay as active as possible and participate in non-weight-bearing activities, such as biking, swimming, or aerobic water exercises.

Be an advocate for the elderly

Promoting health and well-being is the cornerstone of nursing. Once you understand the prevalence and effects of chronic pain in older adults, you can more easily identify patients with debilitating chronic pain, collaborate with a multidisciplinary healthcare team, and implement interventions to provide relief and improve quality of life.

Stay up-to-date on the latest research findings about chronic pain, and use this information to help guide your practice. Provide measures that promote comfort, document patient outcomes, and advocate for elderly patients. Urge nursing leaders to lobby the federal government to fund research related to chronic pain in the elderly, and assist researchers in collecting data as appropriate.

Remember—pain isn’t a normal part of aging. Older adults deserve relief from pain and the stress it creates.

Selected references

Auret K, Schug SA. Underutilization of opioids in elderly patients with chronic pain. Drug Aging. 2005;22(8):642-654.

Bruckenthal P, D’Arcy YM. Assessment and management of pain in older adults: a review of the basics. Topics in Advanced Practice Nursing eJournal. 2007;7(1). www.medscape.com/viewarticle/556382. Accessed August 23, 2010.

Bruckenthal P, Reid CM, Reisner L. Special issues in the management of chronic pain in older adults. Pain Med. 2009;10(suppl 2):S67-S78.

Edwards RR. Age differences in the correlates of physical functioning in patients with chronic pain. J Aging Health. 2006;18(1):56-69.

Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716-2724.

Garcia AD. The effect of chronic disorders on sleep in the elderly. Clin Geriatr Med. 2008;24(1):27-38, vi.

Hainline B. Chronic pain: physiological, diagnostic, and management considerations. Psychiatr Clin North Am. 2005;28(3):713-735, 731.

Hart-Johnson TA, Green CR. Physical and psychosocial health in older women with chronic pain: comparing clusters of clinical and nonclinical samples. Pain Med. 2010;11:564-574.

Higgins I, Madjar I, Walton JA. Chronic pain in elderly nursing home residents: the need for nursing leadership. J Nurs Manag. 2004;12(3):167-173.

Moddeman G. Managing the pain of post-herpetic neuralgia. Clin Nurse Spec. 2006;20(3):128-129.

Pasero C, McCaffery M. Comfort-function goals: a way to establish accountability for pain relief. AJN. 2004;104(9):77-81.

Siedlecki SL. Predictors of self-rated health in patients with chronic nonmalignant pain. Pain Manag Nurs. 2006;7(3):109-116.

Tsai P. Issues and innovations in nursing practice: predictors for distress and depression in elders with arthritic pain. J Adv Nurs. 2005;51(2):158-165.

U.S. Census Bureau, Population Division. Annual estimates of the population by selected age groups and sex for the United States: April 1, 2000 to July 1, 2005. www.census.gov/popest/national/asrh/NC-EST2005/NC-EST2005-02.xls. Accessed August 23, 2010.

Kathleen Peterson is a staff nurse at Miami Valley Hospital in Dayton, Ohio. This article was developed as a component of her honors project while completing her BSN. Gail Moddeman is an associate professor at Wright State University-Miami Valley College of Nursing in Dayton and coordinator of the undergraduate gerontological nursing course.

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