By Christine Haran
Many of us have a grandparent or great-aunt who corners us at family functions to share every ache and pain. While such relatives are often considered cranky curmudgeons, it's also possible that they are one of the many older Americans whose pain is underestimated and under-treated.
Because older people often struggle with a number of medical conditions, they may have different sources of pain, such as arthritis or cancer. And while there will always be that relative who likes to talk about their pain, many older people are reluctant to complain to their families and their doctors because they assume pain is a part of aging. Older people with cognitive problems may even have trouble remembering or describing their pain. Additionally, health care providers do not always try to carefully assess pain in their older patients.
Below, researcher Dr. Bruce A. Ferrell, an associate professor in the division of geriatrics at the David Geffen School of Medicine at the University of California, Los Angeles, outlines how older people and their caregivers can work with their health care providers to better assess and treat pain.
How common is chronic pain in older people?
It's very common. In general, we think that about 12 percent to 25 percent of elderly people have significant pain problems at any one point in time. In nursing home settings, it's suggested that anywhere from about 45 percent to 80 percent of the population have significant pain problems.
What are some of the causes of this pain?
Probably the most common causes are musculoskeletal in origin, such as low back pain and arthritis of the hip, knees, shoulders and hands. Another common cause is related to neuropathies. They're usually injuries or diseases of the nerves associated with conditions like diabetes, shingles or phantom limb pain that we see with amputations or injury from trauma.
Cancer is more common in elderly people and is a source of severe and intense pain for most patients. For those patients, it's very distressing, and very distressing for families and for caregivers, as well.
A lot of elderly people have more than one source of pain. Arthritis is a good example, where they may have more than one joint or one area of the body that's affected at the same time. That sometimes makes diagnosis and treatment difficult.
How can lack of mobility contribute to pain?
There's been an observation that patients who are sedentary in their lifestyle tend to have more musculoskeletal pain. I think most people who sleep late in the morning have experienced stiffness and pain all over when they get up. For elderly people who don't get a lot of exercise on a regular basis, this leads to a vicious cycle. They do less exercise, and then they actually have more pain when they do exercise, so they're less inclined to exercise.
How does pain affect their ability to perform their daily activities?
Initially, pain keeps people from doing the things that they enjoy most. Sometimes that means the ability to get out of the house and socialize or do recreational activities that they used to enjoy.
Later, if the pain gets worse, it can start affecting their activities of daily living such as being able to get up and fix meals for themselves or do any housework. So it's kind of a continuum, depending on the kind of pain and sometimes the intensity of the pain.
Does pain often affect sleep?
It often does, especially for people who have pain intensity high enough that they have to take a lot of pain medications. Sometimes the medications wear off in the middle of the night and people wake up in pain. There are certain kinds of pain that might affect patients more at night such as neuropathies, where sometimes the pain appears to be in the skin or on the surface, and whenever you touch it, it just makes it worse. Every time you get into the bed, just the sheets and the covers can make that pain worse.
Why is pain in older people often underestimated and therefore under-treated?
I think there's a variety of reasons why that occurs. Occasionally we'll find elderly people who are stoic in the way that they approach pain, and they don't like to complain much of pain. We find that a lot of people expect pain as they get older, so they just don't bring it up to their doctor.
Elderly people sometimes use different words to describe their pain. Sometimes they'll just say, "Well, no. I don't really have a pain. It just aches, or it hurts."
Also, elderly people are more likely to have problems with their memory and cognitive impairments. In those kinds of patients, they may not remember the pain that they had this morning or yesterday or last week, so they're much more difficult to evaluate because they just don't complain of it quite as much.
What are barriers to pain management within the health care system?
I think that institutions are going to have to take more of an active role in making sure that they provide the services that are necessary for pain management. And attention to pain management is beginning to occur across the country.
One of the barriers that has been identified for years has been that the laws governing controlled substances in some of our states makes it difficult for patients to get the potent analgesics that they need. There are pharmacies in urban areas, for example, that don't carry those drugs for fear of violence and robbery.
Another barrier has to do with education of the health care providers. Most physicians and nurses weren't taught much about pain during their training programs. They didn't teach us which drug to use in which kind of patient. Now a lot of the curriculums in medical schools and a lot of curriculums in subspecialty training, such as internal medicine, palliative care, oncology, orthopedics and rheumatology, are starting to begin to emphasize skills in pain management.
How is pain in older people usually assessed?
In the majority of elderly people, you can approach pain assessment similar to the way you do in younger people. Today, we use a lot of tools to help us measure pain. Probably the most common one is just simply asking a patient, "On a scale of 0 to 10, how bad is your pain right now?" Once you have a number, then you can go back repeatedly and determine a little more accurately whether your treatment strategies are working.
Where you get into problems with assessment is in elderly patients who have some mild to moderate cognitive impairment. These people have a hard time analyzing, remembering or integrating their pain experiences over time and putting it into a number scale or assigning a word to their pain.
In these patients, behavior can be an indicator of how they're doing. If people obviously wince and have facial gestures and body posture whenever you try to get them up out of a bed into a chair, for example, those behaviors are reliable indications that they have significant pain during those activities. But there is no behavior scale we can use because individual patients have a variety of different behaviors.
How well do older people tolerate pain medication?
Elderly people are more sensitive to the side effects of most medications compared to younger patients, and that can be problematic in terms of treatment. On the other hand, studies suggest that elderly people may also be more sensitive to the pain-relieving effects of these medications, so oftentimes it doesn't take as high a dose in an older person as it might in a younger person to get the same amount of pain relief.
Some drugs also tend to have some interactions with other drugs. You might start one of these drugs and all of a sudden the person's blood pressure jumps up because of a drug interaction with their anti-hypertensive medications.
The rule of thumb is you start with a low dose and you escalate the dose slowly depending on how people's pain responds to it, while at the same time watching for any side effects.
What pain medications are usually used in older people?
We use just about the same drugs in older people as we do in younger people, with different caveats in terms of their sensitivity to side effects. The first choice of most physicians and patients with mild to moderate pain, for osteoarthritis or with musculoskeletal complaints, is probably acetaminophen.
One class of pain medications that are common used is non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen. Those drugs are often used for arthritis and chronic pain problems, but we've found that they have a higher side effect profile in older people than they do in younger people. The major worry is that they can cause gastric ulceration and bleeding. There are some new NSAIDS, however, such as Vioxx, Celebrex and Bextra, that are purported to have less gastrointestinal toxicity.
The third category of pain relievers is the opioids, which are derived from morphine. These drugs are very potent, and they can relieve all kinds of pain, even very severe pain. They also have more side effects than the previous two categories such as drowsiness and nausea, which can be temporary, and constipation, which tends to be an ongoing problem. These are the only class of drugs that can be habit-forming. That means that there is a very small chance that patients will develop a habit using those drugs.
What other treatment options are available?
One of the most important things is probably physical therapy and maintaining good physical conditioning. If people are able to get up, stay moving and keep in shape, everything goes better for them. They eat better, their bowels work better, their pain is better.
There are a variety of other interventions that people can use, such as ice packs and heating pads. For patients who have musculoskeletal problems, sometimes using a hot tub or swimming in pool therapy helps them keep their joints mobile and keep them active.
There are a variety of other interventions such as acupuncture, acupressure and massage therapy. I wish we had more data on these things so that we'd know exactly what to do and when to do it, and which patients benefit most. But I think that they are safe and effective for individual patients, and we should use them for selected cases.
What is your advice to the caregivers of older people who are in pain?
Most of my patients rely on caregivers for a lot of their care, and I think it's important for caregivers to be knowledgeable about the medications that are being prescribed and how to use them appropriately. It's also important for caregivers to know that there are a variety of different strategies in the management of pain.
What advice would you give to older people about how to communicate better with their health care professionals about their pain?
The biggest message is to make sure they tell their health care providers when they're uncomfortable. Sometimes we health care providers tend to be a little bit insensitive about a lot of these symptoms, and sometimes the patients kind of give up on us. Patients should keep telling the doctor about the pain.
There are times when it may be appropriate to seek the advice of a specialist in pain management for severe or complicated problems. In those situations, you may want to ask your primary care doctor for a referral to a pain specialist.
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