Pain in older adults

As I faced challenging pain management in several older adults this week I thought I would touch on some of the principles to consider when managing malignant and non-malignant pain in the elderly.

First and foremost, it can be difficult, and yet managing pain appropriately and effectively in the older adult is as important as managing pain in a younger person. Older adults feel pain and demonstrate significant consequences when their pain is undertreated (sleep problems, functional decline, depression or anxiety, malnutrition, decreased socializing, behavioral problems).

Assessing the pain can be more challenging because most pain scales can be more difficult to use, especially if there is any cognitive impairments. In addition, older adults are less likely to report their pain (concern for treatment interruption, fear that pain represents severe pathology, not wanting to disappoint the doctor, feeling pain is normal or expected or necessary). I suggest individualizing pain assessment by finding a scale that works for the individual patient. Sometimes it is necessary to detect pain by watching the patient walk or move, or during physical exam if there is no verbally reported pain.

Treating pain should be approached individually while also following some general principles. First, setting clear expectations for what you hope to achieve with management: I suggest be clear up front that “pain-free” is unlikely but rather controlling the pain to the point of optimizing their function with the pain is appropriate. Using a multi-modal approach is most effective (medication, behavioral, physical and occupational therapy). Medications should include analgesics by following, for example, the WHO Ladder. Medication management often should include co-analgesics or adjuvant pain relievers such as antidepressants, anticonvulsants, local anesthetics, steroids and antispasmodics.

Finally, careful and close assessment of your interventions is critical. This will allow you to move slowly but steadily towards improved pain control. I often will call these patients by phone one week after an adjustment for a brief pain assessment and see them every two weeks while actively titrating, and then less often once we have optimized the regimen.