Pain Management in Old Age Introduction
Pain is a pervasive and often debilitating experience among older adults. With an increasing aging population, managing pain in this demographic has become a critical issue in geriatric nursing. As we approach 2030, one in five U.S. residents will be over 65, with those over 85 being the fastest-growing segment of the population (Rosenthal & Kavic, 2004). In the year 2000, adults over 65 accounted for half of all hospital inpatient days and approximately 50% of admissions to intensive care units (ICUs) (Rosenthal & Kavic, 2004; McNicoll et al., 2003; Pisani et al., 2003). This necessitates a robust understanding and strategic management of pain in older adults by nurses across all care settings. This article explores pain as a health issue, the challenges of pain assessment in older adults, and both pharmacological and non-pharmacological interventions for effective pain management.
Understanding Pain in Geriatric Nursing
What is Pain?
Pain is a complex, multidimensional subjective experience encompassing sensory, cognitive, and emotional components (Melzack & Casey, 1968). In geriatric nursing, pain is defined as whatever the patient says it is, existing whenever they say it does (McCaffery, 1968). This definition emphasizes that pain is a subjective experience, unique to each individual, and underscores the importance of listening to the patient’s own report of their pain.
Pain in older adults can be broadly categorized into two types: acute pain and persistent (chronic) pain. Acute pain is typically associated with surgery, fractures, or trauma, while persistent pain is often linked to conditions such as osteoarthritis (AGS Panel, 2009). Pain can have profound effects on an older adult’s health, functioning, and quality of life, contributing to depression, social withdrawal, sleep disturbances, impaired mobility, decreased activity, and increased healthcare utilization (Wells et al., 2008).
Pain as a Health Care Issue
The causes of pain in older adults are varied and include both acute and chronic conditions. Acute pain is commonly associated with surgery, fractures, or trauma, while persistent pain, lasting more than 3 to 6 months, is often due to musculoskeletal conditions like osteoarthritis (AGS Panel, 2009). In 2000, nearly 9 million surgeries were performed on older adults, including 1.25 million musculoskeletal surgeries (Herr et al., 2004). Moreover, cancer is a significant source of pain, affecting one-third of patients with active disease and two-thirds of those with advanced disease (Reiner & Lacasse, 2006). Older adults in acute care settings often experience acute pain superimposed on chronic pain, complicating their pain management needs.
Pain has significant implications for older adults’ health, functioning, and quality of life. It is associated with depression, social withdrawal, sleep disturbances, impaired mobility, decreased activity engagement, and increased healthcare utilization (AGS Panel, 2009). Additionally, pain can exacerbate other geriatric conditions such as falls, cognitive decline, deconditioning, malnutrition, gait disturbances, and slow rehabilitation (AGS Panel, 2009). In hospital settings, unrelieved acute pain increases the risk for thromboembolism, hospital-acquired pneumonia, and functional decline (Wells et al., 2008).
Over the past decade, many clinical and empirical efforts have aimed to improve pain assessment and management in older adults. For example, the Joint Commission (2001) recognized pain as the fifth vital sign and mandated appropriate pain assessment and management. This mandate revealed some challenges in assessing and managing pain in older adults, particularly those with dementia. Consequently, numerous clinical guidelines and pain assessment tools have been developed for older adults, especially those with cognitive impairment (Herr et al., 2010).
Despite these efforts, evidence suggests that pain is still inadequately assessed and poorly managed in older adults across care settings (Herr, 2010; Horgas et al., 2009; Morrison et al., 2003; Titler et al., 2009). This chapter provides the best evidence for assessing and treating pain in older adults, particularly those with cognitive impairment, with the aim of establishing and implementing protocols that improve pain management in acute care settings.
Pain Assessment in Older Adults
Challenges in Pain Assessment
Pain assessment in older adults can be challenging due to several factors, including cognitive impairment, communication difficulties, and biases or misconceptions about pain in older adults. Pain is a subjective experience without an objective measure; hence, it relies heavily on the patient’s self-report (AGS Panel, 2009; McCaffery, 1968). However, many older adults may be unable or unwilling to report pain due to cognitive impairment, fear of being labeled as a complainer, concerns about disease progression, fear of addiction to analgesics, worries about healthcare costs, or a belief that pain is unimportant to healthcare providers (AGS Panel, 2002; Gordon et al., 2002).
Self-Reported Pain
Self-report remains the gold standard for pain assessment (AGS Panel, 2002, 2009). The first principle of pain assessment is to ask about the presence of pain regularly and frequently (Pasero & McCaffery, 2011). Different terms such as discomfort or aching should be explored, especially when working with cognitively impaired older adults.
Several tools are commonly used to measure pain intensity, including the Numerical Rating Scale (NRS), Verbal Descriptor Scale, and Faces Pain Scale (FPS). The NRS asks patients to rate their pain intensity on a 0–10 scale and is widely used in hospitals. However, it requires the ability to discriminate differences in pain intensity and may be difficult for some older adults to complete. The Verbal Descriptor Scale is often recommended for older adults, as it asks participants to select a word that best describes their present pain (e.g., no pain to worst pain imaginable) and is found to be more reliable and easier to use (Herr, 2002a).
The FPS, initially developed for children, consists of seven facial depictions ranging from the least pain to the most pain possible and can be used to measure pain intensity, especially among cognitively impaired older adults. However, the FPS has relatively low reliability and validity in cognitively impaired older adults and is not generally recommended for use in this population (Herr et al., 2006).
Pain Indicators for Non-Verbal or Cognitively Impaired Patients
Dementia and other conditions can impair older adults’ ability to self-report pain. For such patients, a hierarchical pain assessment approach is recommended:
- Attempt to obtain a self-report of pain.
- Search for underlying causes of pain, such as surgery or a procedure.
- Observe for pain behaviors (e.g., grimacing, bracing, rubbing).
- Seek input from family and caregivers (Herr et al., 2006; Wells et al., 2008).
If any of these steps are positive, the nurse should assume pain is present and initiate a trial of analgesics. Observational techniques for pain assessment focus on behavioral or nonverbal indicators, such as guarded movement, grimacing, painful noises or words, and restlessness (Horgas & Elliott, 2004). While vital signs may suggest the need for pain assessment, they are not reliable indicators of pain (Pasero & McCaffery, 2011).
Several observational measures, such as the Checklist of Nonverbal Pain Indicators (CNPI), Pain Assessment in Advanced Dementia (PAINAD) scale, and Pain Assessment Checklist for Seniors with Severe Dementia (PACSLAC), have been developed to assess pain in patients who cannot self-report. However, these tools should be used with caution as they do not always reliably indicate pain intensity and should be part of a comprehensive pain assessment.
Interventions and Care Strategies
Managing Pain in Older Adults
The primary goal of pain management in older adults is to maximize function and quality of life by minimizing pain whenever possible (Herr, 2010; Wells et al., 2008). Optimal pain treatment uses a multimodal approach tailored to the patient that combines pharmacological and non-pharmacological strategies. Given the physiological changes that occur with aging, pharmaceutical pain management often becomes more imperative in older adults, especially those with dementia who may have limited cognitive capacity to participate in non-pharmacological pain management strategies (Buffum et al., 2007).
Pharmacological Pain Treatment
Pain treatment with medications involves decision-making based on multiple considerations. It should be a mutual process among healthcare providers, patients, and caregivers, with the goal of optimizing quality of life and functioning (Wells et al., 2008). Effective pain management includes a careful discussion of risks versus benefits, frequent reviews of drug regimens, and the establishment of clear goals of therapy.
Types of Analgesic Medications
Nonopioid Medications: Acetaminophen is considered the first-line drug of choice for mild-to-moderate pain in older adults. The total daily dose should not exceed 4 grams per day (maximum 3 grams per day in frail elders) due to potential hepatic toxicity (Herr et al., 2006).
Opioid Medications: Opioid drugs are effective for moderate-to-severe pain from multiple causes. They can be used safely in older adults when appropriately selected and monitored, although concerns about addiction, side effects, and intolerance often deter their use (AGS Panel, 2009).
To prevent constipation, which is a common side effect of opioids, preventive measures such as stool softeners, adequate fluid intake, and moderate activity should be initiated when opioid therapy is started (AGS Panel, 2002).
Adjuvant Drugs: Adjuvant drugs are administered with analgesics to relieve pain. They can achieve optimal pain control through additive analgesic effects or enhance response to analgesics, especially for neuropathic pain (AGS Panel, 2002; Wells et al., 2008).
Special Considerations for Administering Analgesics
When considering pain medications for older adults, special considerations include the patient’s cognitive status, potential side effects (e.g., sedation, cognitive changes, balance issues), and drug-drug interactions. Recommendations include starting at low doses and gradually titrating upward, using short-acting medications initially, and choosing drugs with a short half-life and fewer side effects whenever possible (Pasero & McCaffery, 2011; Wells et al., 2008).
Non-Pharmacological Pain Treatment
Non-drug strategies are an essential component of pain management. Many older adults use various nonpharmacological modalities, such as relaxation, activity modification, massage, heat or cold application, and movement therapies. These strategies are often used in combination with pharmacological treatments to enhance pain relief (AGS Panel, 2002; Barry et al., 2005; Herr, 2002b).
Types of Non-Pharmacological Treatment Strategies
Physical Pain Relief Modalities: Include transcutaneous electrical nerve stimulation (TENS), physical therapies, heat and cold application, massage, and movement therapies. These modalities focus on physical pain relief and are especially effective for persistent pain management (Furlan et al., 2009).
Psychological Pain Relief Modalities: Include relaxation, distraction, guided imagery, meditation, cognitive behavioral therapy, biofeedback, and hypnosis. These strategies aim to change the person’s perception of pain and improve coping mechanisms (Rudy et al., 2002).
Nonpharmacological treatments can be highly individualized based on patient preferences, response, and specific needs. Older adults often express interest in these approaches, and nurses should consider them as part of a comprehensive pain management plan.
Improving Pain Management in Care Settings
Nurses have a crucial role in assessing and managing pain in older adults. As integral members of interdisciplinary healthcare teams, they must work collaboratively to assess and treat pain effectively. Given the prevalence of pain in older adults and the growing aging population, this role is increasingly important. Nurses are also responsible for educating patients and families about pain management strategies, both pharmacological and non-pharmacological.
Improving pain management in care settings requires strong institutional commitment, the establishment of pain management teams, evidence-based documentation, and a multispecialty approach to pain management. Quality improvement efforts should include educational opportunities, clinical pathways, decision support tools, and access to resources for pain management.
Conclusion
Pain management in older adults is a complex, multifaceted challenge that requires a holistic approach. Effective pain management involves comprehensive assessment strategies, both pharmacological and non-pharmacological interventions, and collaborative efforts among healthcare providers, patients, and families. Nurses play a pivotal role in implementing and optimizing pain management strategies, ensuring that older adults achieve the best possible quality of life. As the population ages, it is crucial that pain management practices in geriatric nursing continue to evolve and improve based on the best available evidence.