Assessment and Management of Pain in Older Adults: A Review of the Basics

Patricia Bruckenthal, PhD, RN, ANP; Yvonne M. D'Arcy, MS, CRNP, CNS

Disclosures

Topics in Advanced Practice Nursing eJournal. 2007;7(1) 

In This Article

Pain Management for Older Adults

Pain management techniques should include both pharmacologic and nonpharmacologic approaches. Common goals are pain reduction and improved function.

Nonpharmacologic Techniques

Some simple comfort measures can help reduce pain. Listening to music, watching television, and storytelling are all distraction techniques that allow patients to reduce their focus on pain. Massage, soft touch, and warm applications are relaxation techniques that are beneficial for patients who are open to these practices. Sensory stimulation in the form of pet therapy or folding warm clothes as well as cognitive therapies that include reading or reminiscing have all been used to reduce pain.[13]

Participation in regular physical activity not only reduces pain, but enhances functional capacity and mood. Therefore, a physical activity program should be considered for all patients. The program should be individualized to meet the needs and preferences of the patient.[14,15] This is especially important for older adults.

There is a wide range of nonpharmacologic interventions that may be helpful to older adults. The choice of intervention should be individually tailored on the basis of preference, ability to participate, and efficacy. Nonpharmacologic interventions may be effective alone or in combination with pharmacologic therapies.

Pharmacologic Pain Management Techniques

Pharmacologic management is the most common treatment for pain control in older adults. There are a variety of pharmacologic agents to treat pain in the elderly, and no 2 patients will respond in the same way. It is important that nurses be aware of specific properties of drugs that are prescribed and common age-related changes that can influence how drugs are metabolized and absorbed.

Starting with a low dose and titrating upward until pain relief is achieved must be balanced with the development of intolerable side effects or toxic serum levels. Using the least invasive route of administration and reassessing the effect of the drug are important components of effective analgesic management.

Older persons are more susceptible to adverse drug reactions for several reasons:

  • Physiologic changes resulting from aging vary among elders.

  • Body fat composition -- that is, muscle-to-fat ratio -- changes as people age.

  • Protein binding affects drug effectiveness. Decreased protein stores due to poor nutrition, for example, will affect the protein-binding capacity of certain medications.

  • Similarly, given that many older adults are on multiple medications, the drugs may compete for protein-binding sites, rendering 1 or more medications ineffective.

  • Functions that affect the absorption, metabolism, and clearance of drugs, including slowed gastrointestinal motility as well as decreased cardiac output and glomerular filtration rate.

  • Changes in sensory and cognitive perception, such as sedation or confusion, may be a risk for some patients due to potential side effects of both opioid and nonopioid medications, such as antidepressants and anticonvulsants.

Acetaminophen is generally considered the first line of treatment for elders with mild-to-moderate pain, especially of musculoskeletal origin. It must be used with caution in patients with:

  • Liver disease;

  • End-stage renal disease; or

  • History of alcohol abuse.

In patients with renal or liver disease a reduction of the maximum daily dose of 4 g of acetaminophen by 50% to 75% has been recommended.[1]

If ineffective, progression to nonsteroidal anti-inflammatory agents is suggested. These types of agents are helpful only for short-term therapy. Gastrointestinal toxicity, platelet dysfunction, renal dysfunction, and sodium retention limit their usefulness in some patients.

Opioid analgesic drugs may help relieve moderate-to-severe pain. Although previously shown to be effective in treating patients with cancer pain, they are emerging as acceptable to use in patients with noncancer pain as well. One of the benefits of these medications is that they have no ceiling effect. In other words, escalating doses will not cause organ damage.[16] They are limited, however, by side effects, such as:

  • Nausea;

  • Vomiting;

  • Itching;

  • Sedation; and

  • Constipation.

Usually, the patient will become tolerant to most of these side effects. If not, it is sometimes helpful to switch to another opioid medication or add an antiemetic. It is important to monitor older people for safety due to dizziness or potential for dehydration due to nausea and vomiting. All individuals on opioids should have a bowel regimen initiated to maintain regularity.

Adjuvant medications are those medications not formally classified as analgesics, but have pain-relieving properties. They have been shown to be most helpful for treating neuropathic pain. Topical agents, such as lidocaine 5% patch (Lidoderm) and capsaicin, have been helpful in relieving pain associated with postherpetic neuralgia and diabetic neuropathy.

Specific antidepressants and anticonvulsants have been helpful in treating various nerve-related pain as well. Side effects, such as dizziness and dry mouth, should be monitored.[16]

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