Treating persistent pain in the elderly

Treating persistent pain in the elderly

Across the globe, persistent (chronic) pain is one of the most common reasons for the elderly to seek consultation with healthcare professionals.

Persistent pain, by definition, continues to affect the person for prolonged periods of time, and may or may not be associated with a well-defined disease. Different bodies have different defined persistent pain of various durations, ranging from three months to over a year.

Persistent pain manifests in various forms. Among the elderly, persistent pain is frequently associated with musculoskeletal disorders, such as a degenerative spine condition and osteoarthritis. Nighttime leg pain, pain from claudication, cancer pain, neuralgia secondary to diabetes mellitus, amputation, peripheral vascular disease, herpes zoster, and pain due to trauma, are common as well.

In the US, it has been estimated that 21 per cent to 70 per cent of community-dwelling older adults (more than 65 years of age) suffer from persistent pain. Other studies have demonstrated that 35 per cent to 48 per cent of older adults in the community are affected by pain on a daily basis, while up to 85 per cent of elderly people residing in nursing homes experience pain.

Notably, persistent pain also affects Malaysian senior citizens. According to the Community Oriented Programme for the Control of Rheumatic Diseases (COPCORD) Study in Malaysia, pain rates increase with age, with up to 53.4 per cent in the age group of more than 65 years experiencing pain.

Low back pain, knee pain and joint pain are the most common complaints among those studied.

The most common disability in the Malaysian survey is inability to squat (3.1 per cent), largely due to knee joint symptoms.

In fact, it is not surprising to observe such a trend, as the average life expectancy of Malaysians has increased. In 2010, approximately 5.1 per cent of the Malaysian population consisted of people aged more than 65 years.

The increasing prevalence of weight problems (overweight and obesity), diabetes mellitus and cancer worldwide, adds to the pain problem.

The National Health and Morbidity Survey III (NHMS III) indicated that 43.3 per cent of Malaysians were either overweight or obese. One in six Malaysian adults above 30 years old had diabetes, making an estimated 1.4 million in total.

Persistent pain is a multifaceted problem. It is associated with many secondary problems, such as disturbed sleep, depression, impaired physical function and disability, decreased participation in social activities, and higher healthcare costs.

Hence, it is not surprising that persistent pain leads to reduced quality of life, often resulting in substantial strain on the relationship between the patient and their caregivers.

Behaviour, attitudes and beliefs

A major challenge in persistent pain management is the under-reporting of pain. There is growing evidence that help-seeking behaviour is closely associated with individual characteristics, attitudes and causal beliefs.

Increasing age, pain severity, female gender, lower education levels and disability have been associated as salient factors for people to seek help for their pain problem.

Stoic attitudes, ie putting up a brave front in the face of pain, has been identified as another factor that leads to under-reporting among older adults.

It is common to hear statements such as "if you have a pain, put up with it" or "what can't be cured must be endured" among this cohort who suffer from pain.

Furthermore, the belief that pain is a normal part of ageing forms barriers in elderly people to seek help.

Drug selection in pain management depends heavily on an individual's physiological factors. Medications may linger longer in the bodies of older adults due to age-related changes in physiological function. These changes include decline in metabolism capacity and excretion rate in the liver, as well as the kidney.

Changes in fat-to-water ratio also affect the volume of distribution of some medications. Slowing the gastrointestinal tract transit time may prolong the effect of continuous release enteral drugs. The elderly tend to experience anticholinergic effects more easily, which is manifested as incontinence, dry mouth, constipation, increased confusion and movement disorders.

Medication safety issues in older adults

Medication safety issues in older adults

Pain management should be evidence-based, where established guidelines and clinical practice guidelines on pain management are referred to when dealing with elderly patients.

Similarly, older people should not self-medicate without referring to a healthcare provider trained in pain management.

The mere fact that many older adults have polypharmacy issues further complicates the matter. Older adults who are exposed to inappropriate drug choices face higher risk of experiencing adverse drug reactions and drug interactions, compared to younger people.

Many drugs that work well in the younger population may not be appropriate in older adults. For instance, long term use of oral nonsteroidal anti-inflammatory drugs (NSAIDs) with long half lives in full dosages, such as naproxen, piroxicam and indomethacin, are not recommended in older adults due to relatively higher risk of gastrointestinal bleeding, renal failure and heart failure.

The use of tricyclic antidepressants (TCAs) in pain management in older adults who have seizures, cardiovascular diseases, and risk of falling should be managed very cautiously. TCAs are contraindicated in patients who are taking monoamine oxidase inhibitors (MAOIs) or selective serotonin reuptake inhibitors (SSRIs), and for patients who have uncontrolled narrow angle glaucoma, hepatic diseases or heart block.

Treatment in persistent pain

Perhaps the biggest misconception about treatment in persistent pain is that many believe that drugs are a panacea or substitute to non-pharmacological therapies.

Another myth is the belief that NSAIDs are effective for all kinds of pain.

Lastly, many are reluctant to use opiods in pain management, largely due to the concern about addiction issues.

In reality, paracetamol (acetaminophen) remains the first-line recommendation among non-opiod drugs in older adults. NSAIDs and COX-2 inhibitors are useful in nociceptive pain, but not neuropathic pain.

On the other hand, antidepressants and anticonvulsants are indicated for neuropathic pain.

The selection of analgesics must be tailored according to the pathology of pain, as well as the mechanism of action of the drug, apart from considering the efficacy and safety factors in older adults.

Research has shown that generally, older adults have lower risk of developing opiod addiction. Nevertheless, opiod users may develop tolerance to the drug and may need higher doses eventually.

Appropriate selection of analgesics at correct doses and frequency is crucial in the older adult. However, despite having a wide choice of pharmacological agents to choose from, persistent pain is best managed together with non-pharmacological modalities.

There is a growing body of literature that shows the combination of pharmacological therapies with non-pharmacological treatments further improves a patient's functional activities, emotional functioning, as well as quality of life.

Achieving 365 pain-free days and a good quality of life is possible, if appropriate multimodal therapies are discussed and planned together by healthcare providers and the patient.

Multidisciplinary frameworks, involving physicians, pharmacists, nurses, physiotherapists and other related healthcare providers, is crucial to ensure pain-free days in older adults.

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