Strategies to Control Pain in Older Persons: Highlights of Recent Guidelines

Persistent pain is common in older adults but tends to be underrecognized and undertreated. Up to 50% of community-dwelling older persons have significant pain,^1-3 and up to 80% of nursing home residents have substantial pain that is undertreated.^4,5 Depression, anxiety, socialization problems, sleep disturbances, impaired ambulation, and polypharmacy are among the consequences of persistent pain.

Since the American Geriatrics Society (AGS) released its guidelines for the treatment of persistent, non- cancer-related pain in older persons in 1998, new analgesics have become available and management strategies have been refined. The AGS recently updated its recommendations to reflect these advances.⁶ Highlights are presented here.

EVALUATION

Assess all older persons for evidence of persistent pain. If pain impairs quality of life or ability to function, further assessment is warranted. A comprehensive evaluation includes:

• Specific assessment of the pain complaint, including intensity, character, frequency and/or pattern, location, duration, and precipitating and relieving factors.
• Use of standard pain scales, such as visual analogs and questionnaires, for patients who are cognitively intact or who have only mild to moderate dementia. [Editor's note: For examples of pain scales, see "Pain in Elderly Patients: How to Achieve Control," CONSULTANT, October 2001, pages 1597 to 1608.] If the patient has moderate to severe dementia or cannot speak, observe him or her for evidence of pain-related behaviors during movement or interview the caregiver.
• A complete history of analgesics and other pain-relieving treatments. Include complementary, alternative, and over-the-counter remedies, as well as prescription agents and traditional therapies, and alcohol use.
• Discussion of the patient's attitudes about pain and its management.
• Assessment of physical function, with emphasis on activities of daily living, pain-associated disabilities, and performance measures of function, such as range of motion.
• Evaluation of social function, including mood and social networks.
• Focused examination of the musculoskeletal and neurologic systems.

Have the patient or caregiver keep a pain log or diary to record pain intensity, medication use, response to treatment, and related activities. Reassess the patient periodically to detect improvement, deterioration, and complications associated with treatment.

PHARMACOLOGIC TREATMENT

Start with the lowest anticipated effective dose of an analgesic that poses the least risk of adverse effects, and slowly increase the dosage if needed. However, if the patient has severe pain, more rapid titration is required to control symptoms; consider hospitalizing the patient during titration.

Nonopioid analgesics. Acetaminophen is the drug of choice for mild to moderate musculoskeletal pain (Table 1). If the maximum dosage of acetaminophen is ineffective, NSAIDs may be helpful. Avoid traditional nonselective NSAIDs for patients who require long-term, daily treatment. Instead, prescribe cyclooxygenase-2 selective agents; nonacetylated salicylates also may be tried.

Opioid analgesics. Opioids alone or in combination with other agents may be appropriate for patients with moderate to severe pain. Table 2 lists recommended regimens of opioids.

Start these drugs at a low dosage and increase slowly as needed. Monitor patients for adverse effects of opioid therapy, such as gait disturbance, dizziness, pruritus, constipation, abdominal distention or discomfort, nausea, sedation, and impaired concentration.

Adjuvant agents. Antidepressants, anticonvulsants, antispasmodics, antiarrhythmics, and local anesthetics have been used alone or in combination with analgesics to manage pain in some patients-especially those with neuropathic pain. Because the newer anticonvulsants are associated with a relatively low incidence of adverse effects, they may be a better choice than the older tricyclic antidepressants.

Placebos have no role in the management of persistent pain.

NONPHARMACOLOGIC STRATEGIES

Nondrug interventions can improve functioning and enhance the effectiveness of pharmacologic therapy. Patient education that includes pain self-management and coping strategies is vital. Education programs are beneficial for the family and caregivers as well.

Cognitive-behavior therapy conducted by a trained therapist is helpful alone or when combined with pharmacologic therapy.

Individualized-and supervised, if necessary-physical activity programs offer a myriad of psychological and physical benefits. These programs improve flexibility, strength, and endurance.

References:

REFERENCES:

1.

Helme RD, Gibson SJ. Pain in older people. In:Crombie IK, Croft PR, Linton SJ, et al, eds. Epidemiologyof Pain. Seattle: IASP Press; 1999:103-112.

2.

Blyth FM, March LM, Brnabic AJ, et al. Chronicpain in Australia: a prevalence study. Pain. 2001;89:127-134.

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Mantyselka P, Kumpusalo E, Ahonen R, et al. Painas a reason to visit the doctor: a study in Finnish primaryhealth care. Pain. 2001;89:175-180.

4.

Ferrell BA. Pain evaluation and managementin the nursing home. Ann Intern Med. 1995;123:681-687.

5.

Bernabei R, Gambassi G, Lapane K, et al, for theSAGE Study Group. Management of pain in elderlypatients with cancer. Systematic Assessment of GeriatricDrug Use via Epidemiology. JAMA. 1998;279:1877-1882.

6.

American Geriatrics Society. The management ofpersistent pain in older persons. AGS panel on persistentpain in older persons. J Am Geriatr Soc. 2002;50(suppl 6):S205-S224.