Key points

Chronic persistent pain affects at least 50% of community-dwelling older adults.

Physiological changes that occur as a result of the ageing process need to be considered when dealing with pain in the older adult.

Assessment of pain can be complicated when the older adult is unable to articulate their pain; for example, in the presence of cognitive impairment.

Much of the research into pain management has been carried out among the younger population and simply translated across.

1 Introduction

Evidence suggests that pain is a common problem for older people, with chronic persistent pain affecting at least 50% of community-dwelling older adults. Pain foci most often cited in prevalence studies are knees, hips, and back. It is believed that the incidence of pain in the oldest and most vulnerable people, such as those living in care homes, increases to 80%.

2 Chronic and acute pain

Cancer is the second leading cause of death for adults over the age of 65 years (1) and it has been suggested that approximately 26% of cancer patients over the age of 65 years suffering daily pain did not receive any analgesic agent (2); thus both chronic and cancer pain control is an issue for the older population. It is important to differentiate between these two major classifications as management is very different. Often there is the assumption that chronic pain is part of getting older and something that the individuals must learn to live with. Nevertheless, we are seeing increasing publications on chronic pain management for older adults and there is a growing awareness that self-management of chronic pain is a viable strategy for this population (3).

Chronic pain is something that exists beyond the expected healing time and is something that often has no identifiable physical cause (4). Acute pain, on the other hand, is a sign of injury or disease, is treatable or even curable and as such, it would be expected that older adults would fare better with the management of acute pain. Yet Desbiens et al. (5) demonstrated that 46% of older people admitted to hospital report pain and 19% of these individuals have moderate or extremely severe pain; 13% were dissatisfied with their pain management.

3 Pain management

Why is pain so difficult to manage in our older population?

It has been suggested that admission to hospital for patients over the age of 65 years is three times higher than their younger counterparts and that professionals tend to underestimate pain needs, underprescribe, and undermedicate (6). We may assume that with high numbers of older adults seen in hospital, staff would be more experienced in dealing with their specific problems; in particular, more skilled in the techniques associated with assessment and management of pain. Unfortunately this is not the case. Negative attitudes to pain management in the older adult among health professionals pervade, with fears and misconceptions regarding interaction between pre-existing co-morbidities and the prescription of analgesic drugs. Such concerns are not totally unfounded as older adults are also likely to have diminished functional status and physiological reserve, as well age-related pharmacodynamic and pharmacokinetic changes (7). Furthermore, cognitive impairment can prevent pain assessment being carried out.

Ageist attitudes towards the older adult may exist: we assume they get used to pain or it is a natural part of ageing. We also know that health care professionals become desensitized to pain as they become more experienced.

4 Physiological function and ageing

Some changes that occur within the anatomy and physiology are considered a normal part of the ageing process; these have been discussed in other chapters. However in relation to pain, there are a number of important considerations. There is an age-related reduction in β endorphin content and GABA synthesis in the lateral thalamus, and a lower concentration of GABA and serotonin receptors. There is an age-related capacity or speed of processing of nociceptive stimuli and c and Aδ fibre function decreases with age (8). The potential for cognitive impairment increases with age and this is aggravated by pain and pain medications. Of particular note is the new belief that respiratory depression associated with opioids is more likely to be a result of the higher plasma concentration of opioids rather than a sensitivity to the respiratory depressant effects, as previously thought (9).

Ageing is also associated with a reduction in renal plasma flow of about 10% per decade (10) and a decrease in liver mass annually of about 1% (11). As discussed by Jackson in Chapter 5, hepatic and renal function changes can lead to altered clearances of medications that may lead to increased sensitivity to drugs, including pain medications.

4.1 Pain threshold

There has been much debate within the literature as to whether or not pain perception threshold increases with age. Gibson and Farrell (12) suggest that the threshold for pain is increased in older people when the stimuli are shorter, are distributed over a lower spatial extent, or are presented at peripheral cutaneous or visceral sites. Similarly, Helme et al. (13) suggested that older adults have an increased threshold for thermal and electrically induced pain.

However, more recent studies by Farrell (14) propose that pain is present in the same format regardless of age. Thus the experience of pain is exactly the same regardless of age; it is the perception and consequential behaviours that may vary. So pain in the older adult is influenced by both intrinsic factors, such as physiological changes, and extrinsic factors, such as barriers, attitudes, and beliefs of health care professionals.

5 Dementia and pain

As mentioned earlier, adults over the age of 80 are more likely to experience pain and also are more likely to have cognitive impairment, which can prohibit effective pain assessment and management. This has been demonstrated in a study by Conway and Schofield (15) who showed that in 368 care homes in one area, of more than 10,000 residents, more than 6,000 had dementia. Pain often presents as ‘challenging behaviour’ in this group, and can be reduced significantly by using simple analgesics such as paracetamol (16). Where individuals are unable to verbalize pain, behavioural tools can be used as a surrogate measure.

As our population ages, there will be increased numbers of adults with dementias. This can be problematic for the patient who may no longer be able to articulate their pain in a language that we can understand. So typical pain assessment measures may not be applicable and we may have to resort to behavioural scales.

6 The assessment of pain

In September 1990 the Royal College of Surgeons and the College of Anaesthetists published the report of their working party, ‘Pain after Surgery’ (17). This report can be accessed from any library or anaesthetic department and makes recommendations regarding the management of post-operative pain in the UK. These recommendations have been implemented widely and have significantly changed all aspects of pain management. One of the key recommendations was that assessment of pain should be recorded along with other routine observations such as blood pressure and pulse. The Joint Commission on Accreditation of Healthcare Organizations (18) also suggests that pain should be recognized as the fifth vital sign. The multidimensional character of pain is emphasized by the National Guidelines for Assessment of Pain for Older People (19), which describe pain at several levels:

the sensory dimension: the intensity, location, and character of the pain sensation

the affective dimension: the emotional component of pain and how pain is perceived

its impact: the disabling effects of pain on the person’s ability to function and participate in society.

A review of the literature related to pain assessment highlighted 42 articles written since 1995 that use various pain assessment tools with the older adult (20). From this work it can be seen that there has been very little research related to older adults and there is a need for more work to be carried out in order to investigate the most appropriate tools. Generally it has been found that this age group prefers the verbal descriptors (none, mild, moderate, severe) or the numerical rating scale, which can be accessed from the British Pain Society website (<http://www.britishpainsociety.org/>) (21). Interestingly, the literature suggests that the faces scale is not popular with this age group as the facial expressions are associated with mood. Clearly more research is needed in this area.

In summary, the numerical rating scale and the verbal descriptor scale are the most appropriate to measure pain in older adults with mild to moderate dementia. When severe dementia is present we need to consider alternative methods of assessment.

In the same literature review cited previously (20

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