Elsevier

Medicine

Volume 45, Issue 1, January 2017, Pages 41-45
Medicine

Medicine in older adults
Pain management in older adults

https://doi.org/10.1016/j.mpmed.2016.10.005Get rights and content

Abstract

We are seeing a significant increase in the older population far outweighing that in younger cohorts, and this is set to dramatically increase by 2050. With increasing age comes an increased risk of co-morbidities and consequently a likelihood of pain. Pain is a common problem for older adults; many reports suggest that the incidence is around 50% in older adults living in the community, increasing to 80% among the nursing home population. Dealing with pain in this population is complex and becomes even more challenging when cognitive impairment exists. This article highlights the challenges, proposes strategies for the assessment and management of pain in the older population and makes recommendations for future research in this area.

Introduction

Our population is ageing, with a significant increase in the number of older adults anticipated over the next 25 years, and a decrease in younger counterparts. So we are expecting to see the ratio of older adults increase to that of younger adults. With this will come a higher number of older adults with cognitive impairments. There are already around 850,000 older adults with dementia in the UK. Therefore an ageing population coupled with an increase in co-morbidities and potential communication difficulties is likely to present future challenges to pain assessment and management.

Historically, evidence has suggested that pain is a common problem for older people, with chronic persistent pain affecting at least 50% of community-dwelling older adults, the figure increasing to 80% among those living in care homes. More recent systematic reviews of the literature confirm that this is still the case.1 As the percentage of our ageing population increases over time (Figure 1), greater demands will be placed on healthcare professionals and informal carers to cope with the problems associated with old age, especially pain assessment and management.

Pain management in older adults is generally poor. The rate of admission to hospital for patients >65 years of age is three times higher than for younger people, and there is evidence that professionals tend to underestimate pain needs, underprescribe and undermedicate. This may in part relate to fears and misconceptions among prescribers regarding pre-existing co-morbidities and the effects of prescribed medicines. Such fears and anxieties are not totally unfounded as older adults tend to have co-morbidities, with concurrent medications prescribed. They are also more likely to have diminished functional status and physiological reserve, as well as age-related pharmacodynamic and pharmacokinetic changes. Cognitive impairment can prevent or complicate adequate pain assessment. In all care settings, healthcare professionals should be aware of pain assessment tools that can be used with older adults – both those who can communicate their pain and those unable to do so as a result of cognitive impairment.

It is frequently assumed that chronic pain is simply a part of getting older and something the individual must learn to live with. However, there is a growing body of research into chronic pain management for older adults, and increasing awareness that self-management of chronic pain is a viable strategy for this population regardless of level of cognitive ability.1

Section snippets

Pain assessment

The American Pain Society has stated that pain is the ‘fifth vital sign’,2 emphasizing the importance of routine and systematic assessment and monitoring similar to that undertaken for respiration, pulse and blood pressure; it is therefore not an assessment to be avoided because it may be challenging.

Pain assessment is now considered to be the fundamental first step in the complete pain management process, and many healthcare professionals carry out effective pain assessment in most areas of

Behavioural pain assessment

Observation is a vital tool when assessing the existence or intensity of pain, particularly in patients who have communication problems, such as cognitive impairments or visual and hearing problems. Commonly cited indicators include facial expressions and body movement (guarding to protect against pain) and physical indicators such as pallor, tachycardia and hypertension.

Over the last two decades, a number of pain scales have been designed to measure behaviours associated with pain. At least

Management of pain

The UK national pain management guidelines for older people were published in 2014.5 Key points included the use of drugs such as paracetamol as the first line of treatment for acute or persistent pain, emphasizing that alternatives, including opioids, could be used if necessary on a ‘start low, go slow’ basis. Non-steroidal anti-inflammatory drugs (NSAIDs) have a place, but only for short-term use (Table 2). There are also alternative approaches such as psychological therapies and

Key references (5)

There are more references available in the full text version of this article.

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