Pain, like many symptoms in older adults, is often attributed to the aging process by older adults and by their health-care providers. The myth that illness and its associated suffering are an inevitable part of aging threatens the care of older patients. However, it is true that older adults may be predisposed to suffering from pain since the incidence of multiple chronic illnesses associated with pain tends to increase with age.
Pain can be emotionally and physically crippling, and can severely threaten the older person's functional ability. Therefore, it is imperative that the older individual adopt a coping response such as seeking treatment and using effective self-care techniques that minimize threats to functional ability. Nurses are faced with the obligation to assist the older adult to develop and implement effective pain management strategies.
Management of pain in older adults requires an understanding of physiological and psychological variables that influence the experience of pain. In addition, knowledge about the epidemiology, interpretation, and clinical presentation of pain enhances effective management. A brief discussion of these concepts is presented in this article.
Epidemiology of Pain in Older Adults
Information about the prevalence of, and responses to pain in older adults has been based largely on data from pain clinics, symptoms reported to doctors, and data on specific diagnostic categories.1,2 Most available information about pain in older adults has focused on malignancy and neglected the prevalence of cardiovascular and musculoskeletal diseases and their accompanying discomfort.3 Aging does not necessarily imply illness. Yet, the aging process does affect changes in the structural and functional processes of the body, predisposing it to a variety of chronic illnesses.4 Butler and Gastel estimate that over 85% of older adults have at least one chronic condition that may create pain.3
Pain is a subjective experience and as a result, is difficult to communicate.5 There seems to be a trend toward underreporting pain symptoms by older adults.6,7 The combination of these factors makes suspect that data about pain obtained through surveys of reported symptoms to physicians. In addition, the typical patient treated at a pain clinic is not sufficiently representative of the general older adult pain patient because a lower proportion of older patients is seen in a pain clinic setting.8
Also, patients who are treated at pain clinics tend to differ from those in the general population.9 Pain clinic patients have typically gone through many referrals and may have numerous social problems as well as a complex psychological profile that includes depression and a tendency to somaticize.9 It is difficult to infer information from pain clinic data about pain in the general older adult population. Consequently, there is a need for more knowledge about the epidemiological nature of pain experienced by older adults.
Some recent research attempting to establish the presence of and response to general physical and mental symptoms in older adults provides some insight into the prevalence of pain in this population.2,6,7 Pain was a frequently reported symptom in these studies.2,7 Brody and Kleban noted that pain was the most frequently reported symptom accounting for 38% of all reported symptoms.2
The three most reported types of pain in order of occurrence were pain in the extremities, hip, and back; head pain; and chest pain.2 Pain also significantly interfered with activities such as physical movement, sleep, social, and leisure activities.2 There is also evidence that pain prompts possibly inappropriate responses such as experimentation with over-the-counter medications, abuse of prescriptions for other illnesses, and delay of attempt to seek treatment.6,7 A definite need exists for increased knowledge about the prevalence of pain and experience of pain in this age group.
Influence of Aging on the Interpretation of Pain
Some of the literature suggests that growing older is accompanied by reduced sensitivity to pain. Studies about the relationship of age to the sensation and perception of pain have produced conflicting results. The majority of these studies have focused on age differences in pain threshold in crosssectional samples in the laboratory. Available data have provided beneficial insight into the sensory aspects of aging and pain, but relevance to clinical pain has not been clearly established.10
Results of studies that use pain induced by radiant heat generally reveal that the pain threshold of older adult subjects is greater than the threshold of younger subjects.11-15 However, Procacci et al15 believe that the difference in pain thresholds may be due to the increased heat dispersion of aged skin. Aging skin does, in fact, undergo changes that may account for the noted difference in threshold using radiant heat.16
Threshold is primarily an indication of the sensory aspects of pain. However, it is known that pain is much more than just a sensory experience. Pain tolerance, rather than pain threshold, may be more relevant to actual clinical pain because tolerance allows for the interplay of psychological variables such as anxiety that influence pain perception and response.10 In another study, pain was induced by pressure on the achules tendon and tolerance was found to decrease with increasing age.17 However, the implications of this finding for clinical pain still are not clear.
One model of pain measurement that includes both psychological and physiological variables is called Sensory Decision Theory (SDT). SDT is a statistical model that yields two types of variables, discrimination ability, and response bias.18 The first variable, discrimination ability, is a measure of the ability to detect a stimulus. Response bias is the willingness to label the stimulus as painful or not painful.
Clark and Mehl employed radiant heat pain induction and used SDT to interpret the results.19 They concluded that older adults were more likely to endure more pain before reporting it. They also concluded that reported age differences in pain "threshold" are caused by a variation in the criteria used for reporting pain, response bias.
In other studies using SDT as a framework, pain was induced by electrical stimulation to the teeth.20,21 These studies did not show age differences in the initial detection of a stimulus, but found that older adults were less able to discriminate between shock intensities than were younger adults. The researchers also noted that at lower levels of perceived stimulus older adults were not as willing to label the stimulus as painful as were the younger subjects.
Based on the above studies, it is difficult to make relevant conclusions about the experience of clinical pain by older adults. It is not clear if the results were affected by actual changes in neurophysiology, attitudinal variables, cognitive factors, or a combination. There is a significant deficit in the literature concerning attitudinal components of the pain experience in the older adult population. As alluded to in the SDT experiments, these may be the more influential aspects in the interpretation of pain by older adults.
In addition, there is some recent evidence that older adults do attribute certain symptoms to the aging process,22 and this attribution influences the coping responses to the symptoms.23 Illnesses and symptoms perceived to be caused by aging were seen as more serious, less controllable, less curable, and less preventable.23 It is possible that older adults may perceive pain in a similar manner; consequently, their responses to pain would be influenced by this perception.
Clinical Presentation of Pain in Older Adults
Knowledge gained from the above studies does not provide a clear indication of what influences clinical presentation of pain in older adults. There is a surprising lack of research on how the manifestation of pain may change with aging. Yet, clinical evidence suggests that the pain presentation may be qualitatively different in older adults.
Pain interpretation by older adults and its diagnosis by the health-care provider are complicated by the presence of multiple diseases with vague symptoms that may affect similar parts of the body.3 These complications frequently contribute to atypical presentation of painful conditions by this age group. For example, pain is often not the presenting complaint by the older patient experiencing an acute myocardial infarction.24 Moreover, chest pain may also be a symptom of arthritis of the spine, herpes zoster infection, or an abdominal disorder.25
Similarly, acute abdominal pain in older adults requires careful investigation. Complaints of severe abdominal pain by the older adult that are not consistent with the tenderness caused by examination may indicate vascular compromise.26 Appendicitis is often misdiagnosed because of a blunted inflammatory response.27 Pain in older adults is typically referred from the site of origin.28 Degenerative skeletal disorders such as kyphosis and osteoporosis of the spine may cause chronic abdominal pain.3
Headache may also present differently in the older patient. Headache that is unrelieved by simple analgesics may signal transient ischemie attack,29 cervical osteoarthritis, subdural hematoma, or cranial bleeding.30 New onset of migraine headaches is rare in older adults and demands special investigation. Temporal arteritis and cranial arteritis are conditions occurring mainly in this age group and should be suspected in the older patient who develops headaches. An elevated erythrocyte sedimentation rate is often indicative of arteritis and immediate diagnosis and treatment with steroids is required, or blindness may result.30
Cognitive disorders may also influence the presentation of pain. A minor trauma that could result in a bone fracture in an osteoporotic individual may have been forgotten or not associated with pain that develops later, thus the pain appears to have an insidious onset.28 Similarly, the etiologic rash of post-herpetic neuralgia, common in older adults, may be gone when the patient presents with pain.28 Depression is a well-documented problem in the older adults and may modify the perception of pain by exaggeration.10 Pain may also be a manifestation of depression or functional impairments such as memory loss or motor difficulties and attributing these symptoms to pain allows the individual to mask the true problem.10
These conditions represent only a few of the variables that may affect the older individual. However, there is a lack of empirical data about age-related changes in the presentation of painful disorders. The complex biomedicai disease presentation, tendency for referred pain, and influence of psychosocial variables should be considered when evaluating pain in the older adult population. It is also important to consider that the attribution of pain to the aging process may result in a passive response by the older individual as well as the health-care provider.23
Management of Pain in Older Adults
Since disease in older adults is often mult isy stem ic with atypical presentation, a complete assessment of pain is the first step in effective management. Duration, onset, quality, precipitating factors, and intensity of the pain need to be assessed. If the older person has cognitive limitations, it is imperative that a close contact (e.g. spouse) be included in the evaluation process. A minor incident such as stepping off a curb may be enough to cause a fracture of an osteoporotic bone, but, as noted before, the patient may not associate the event with the pain.28
Sudden changes in effect, onset of confusion or behavior changes may be the only indicators of pain development. It is helpful to know how the individual expresses the pain. Is the pain communicated behaviorally or verbally? Knowing this will help develop a reliable indicator of the efficacy of pain relief measures.
It is also important for the nurse to assess how the pain is affecting the patient's life. Nursing diagnoses for the patient in pain are frequently limited to "alteration in comfort related to pain." This diagnosis gives no indication of what the pain means to the patient. Is the pain limiting ADLs? Is the pain becoming an overwhelming emotional burden? How is the expression of pain affecting social relationships? Is the pain perceived as controllable or just an inevitable aspect of aging? What are the coping mechanisms used to deal with pain, and are they effective? These are crucial areas to be reviewed with the older patient and family, and they form the bases for effective interventions.
Nursing approaches to the management of pain in older adults need to consider the multiple physical and social problems frequently encountered in this age group. Pharmacological treatment is a basic component of pain control but some modification may be necessary with the older person. Nonsteroidal anti-inflammatory drugs (NSAIDs) continue to be the most effective medications for mild to moderate pain, especially pain associated with inflammatory arthritic conditions.10 However, toxicity may develop more quickly in the oíder person. NSAIDs are bound to serum-proteins; therefore, interaction with other medications such as many ant ihypertensives may occur.
CNS side-effects like depression or confusion may result particularly from indomethacin and naproxen. The GI disturbance often associated with aspirin can be limited by taking it in the enteric-coated form or with food. The patient should also be taught to monitor for tinnitus when taking aspirin. Acetaminophen is an effective analgesic but is not antiinflammatory, and hepatic damage can result from overdosage or prolonged use.
When pain cannot be controlled by simple analgesics, narcotics should be considered and can be safely used.31 Narcotics appropriate for older adults should be short-acting for more effective dosage adjustment and available in a convenient form.31 Some older adults are more susceptible to side-effects of narcotics because of changes in serum proteins, increased proportion of fatty tissue to muscle, decreased glomerular filtration, decreased liver function, and decreased cardiac output.10 These changes affect drug distribution and clearance and predispose the older person to toxicity. Consequently, a smaller dose is usually required but should be titrated for relief. An initial low dose that is gradually increased to allow for maximum pain relief for at least 4 hours is recommended.10
Short-term management of acute pain can be enhanced by the use of propoxyphene or codeine; aspirin or acetaminophen can be added if necessary.31 Morphine or hydromorphone are the narcotics of choice for long-term management of severe pain.31 These are short-acting and come in several convenient forms. Meperidine use should be avoided in this age group because of toxicity from the accumulation of a metabolite, normeperidine, that causes symptoms varying from mild mood swings and tremors to seizure activity.31
As with anyone who is taking narcotics, the older person should be monitored for side-effects, particularly CNS changes, respiratory depression, urinary hesitancy, nausea, vomiting, and constipation. These may become as aggravating to the older adult as the pain. Smaller doses taken on an around-the-clock schedule instead of p.r.n. enhance control of pain and adjustment to side-effects.31 Frequently older adults receive multiple medications, so it is prudent to assess for interactions and avoid combinations of narcotics.
A definite termination date should be set for the use of narcotics in the treatment of acute pain. Development of a bowel regimen and increased bulk in the diet can help combat constipation. Hypnotics and sedatives should be avoided because of the CNS sideeffects.31 These medications do not enhance pain control and may interfere with behavioral approaches to pain management.31 Nighttime narcotics should assist with controlling sleep disturbances resulting from pain.
Since pain is an intensely personal experience, it can quickly become exhausting. Chronic pain can lead to loneliness, dependency behaviors, depression, and isolation. Long-term pain can become the dominating force in the individual's life and the focus of all energy. Behavior and thought patterns develop over time in response to pain. A self-perpetuating cycle between pain and maladaptive coping responses becomes difficult to break. Behaviors such as withdrawal, dependency, and medication use may be perceived as rewarding consequences of pain expression and become established ways of coping with chronic pain.10
Individuals whose coping mechanisms for pain have broken down, may benefit from a pain clinic. Pain clinics use a multimodal approach and emphasize the cognitive and behavioral adjustments to pain in an interdisciplinary setting. The behavioral approach reinforces activities not connected to pain and discourages pain behavior by selectively ignoring pain complaints.10 The patient can also learn stress management, biofeedback, and exercises.
A nonpharmacological approach is emphasized in most pain clinics, but the patient who suffers from depression may benefit from antidepressants. Some antídepressants such as amitriptyline and doxepin may have analgesic properties in addition to their psychotropic effects.10 However, these two drugs have a high sedative effect and must be used cautiously in the older adult.26 In addition, amitriptyline has significant anticholinergic sideeffects.26 Nortriptyline has relatively mild anticholinergic side-effects, is less sedating, and causes less postural hypotension; therefore, it is a more appropriate antidepressant for the older adult.26
Many of the principles of narcotic administration also apply to antidepressants. It is important to consider the sensitivity of the older adults to the cardiovascular, CNS, and anticholinergic side-effects of many antidepressants and assist the patient to manage these problems. Teach the patient about the possibility of postural hypotension and dizziness, and emphasize the importance of altering activity during peak drug activity. Administration at bedtime may eliminate some of these difficulties.
Good oral care is mandatory to combat the effects of decreased saliva from the anticholinergic activity. Urinary hesitancy and constipation may be particularly bothersome to the older person and alternative therapy should be considered if these side-effects cannot be managed.
Simply encouraging exercise can help control pain as well as increase social contacts which can then diminish depression. Developing an exercise program can also enhance the quality of life by creating goals to strive for and increase functional abilities.
Management of pain in older adults is a multi-faceted problem. It is not clear if aging causes changes in the peripheral or central processes of pain sensation and perception. However, pain presentation in this population has been shown to vary and requires thorough assessment. Pharmacological management is effective and can be enhanced by scheduled administration. Close follow-up to monitor for sideeffects, interactions, and efficacy of the medications is imperative. Nonpharmacological approaches (e.g. exercise) that de-emphasize pain behaviors and encourage increased social contact are also important in the management of long-term pain.
Finally, it is detrimental for the health-care professional or the patient to simply attribute pain to the aging process. Pain control is an attainable goal that will enhance the life of the older person.
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