Chapter 57. Pain in the Elderly

Pain is one of the most common complaints among older people. Conditions such as gout, diabetic neuropathy, herpes zoster, peripheral vascular disease, and cancer are more common with increasing age. The most common complaints are musculoskeletal-related problems such as low back and joint pain. In community dwelling elderly, the prevalence of pain has been estimated between 25% and 50%,1 with the prevalence of pain complaints being twice as great in those older than age 60 than in those younger than 60 years old.2 The prevalence of pain in nursing homes is even higher, ranging between 45% and 80%.3-5 In fact, 25% of nursing home residents with nonmalignant pain experience pain on a daily basis,6 and up to 40% of nursing home patients with cancer have pain on a daily basis.7 Unfortunately, the older patient is also at risk for undertreatment of pain. A significant number of elderly people with daily pain do not receive any or enough analgesics. This may be the result of inadequate pain assessment, societal misconceptions about pain in the elderly, as well as the fear of side effects of medications.6,7

The management of pain is already quite challenging. However, the management of pain in the older patient often presents additional challenges. These include underreporting of symptoms, multiple medical problems, medication side effects, problems with assessment, problems with communication, mobility and safety issues, as well as consideration of the potential for medical, cognitive, and functional decline.

History and Physical Examination

The medical evaluation should begin with a thorough history and physical examination. Because the prevalence of musculoskeletal and neurologic conditions increase with age, special attention should be given to these aspects of the history and physical examination. If the cognitive status of the patient is in question, speak with the primary caregiver to obtain a more reliable history. Always ask about falls and occult trauma in the older population. We should also remember that immobility, contractures, and muscle strain can also be potential sources of musculoskeletal pain. Range-of-motion maneuvers and functional evaluation may reproduce pain and assist in functional assessment. A neurologic examination should also be performed, looking for signs of autonomic, sensory, and motor deficits in order to rule out neuropathic conditions. In addition to establishing a diagnosis, a baseline description of their pain should be made, including intensity, frequency, duration, character of the pain, as well as precipitating and relieving factors. Because many older persons may not refer to their discomfort as pain, but rather use other descriptors such as “ache” and “hurt,” we should try to use their language when eliciting a pain history. Documentation of the location of all sites of pain will enable health care professionals target their assessments and determine the functional implications of the pain. It is also helpful to review previous experiences with analgesics, or other therapies. Problems and procedures for the assessment of pain are discussed in the following sections.

Problems with Adequate Assessment

Pain symptoms are frequently underreported in older patients. One study found that 56% of day-to-day health symptoms of older persons (e.g., pain, fatigue, depression) were not reported to health professionals. Some reasons given included responses such as, “the symptoms were no big deal”; “nothing can be done about it”; and “don’t want to bother people.”8 Other explanations may include the belief that pain is a natural part of aging, as well as the fear of certain medications or treatment. Thus, decreased reporting of pain by older individuals may have a lot to do with the attitudes and behavior of older people, family, and health professionals. Furthermore, there are special problems in obtaining an accurate history and pain assessment in this population because of cognitive impairment, depression, and reduced vision and hearing that may require modifications in the assessment techniques. However, in cognitively intact community dwelling elders with chronic low back pain, self-reported pain is associated with more pain behaviors (e.g., guarding, shifting weight, slower movements), particularly when observed with testing of activities of daily living (ADL) functions. Therefore observation of pain behaviors, especially during performance of ADL activities, may also be another important method for assessing pain in the elderly.9

The presence of dementia compounds the problem of underreporting of pain symptoms. Cognitive impairment is associated with decreased reporting of pain.6,10,11 Even persons with mild cognitive impairment who are usually able to understand others or make themselves understood, but have difficulties with short-term memory and new situations, appear to have fewer pain complaints than their cognitively intact peers.6 For this population, we suggest asking about pain symptoms more frequently and regularly, as well as monitoring for pain behaviors more closely.

Patients with mild to moderate dementia have difficulty communicating and may not be able to quantify or describe their pain experience with great detail. However, they can still communicate basic needs in a qualitative way. Because persons with dementia may have difficulty with abstract or complex sentences, as a general rule, always try to speak clearly and keep sentences short, simple, and concrete. Questions should not be open-ended, or require a response to more than two or three choices. Eliciting yes or no responses may be easiest. For example, instead of asking, “What makes your pain worse?” ask “Does your knee hurt more when you walk?” If the patient does not seem to understand you, do not simply repeat the question in a louder or slower voice. Change the sentence and use simpler and different words to explain yourself.

Documenting Pain

A variety of pain assessment tools have been developed in an attempt to document and follow pain symptoms over time. Unidimensional scales, which measure only one element of the pain experience, such as intensity, are used more frequently. Commonly used scales to measure pain intensity include the visual analog scale (VAS), the numerical rating scale (NRS), and the verbal descriptive scale (VDS). The VAS is a 10-cm line, the ends of which are anchored with descriptors of the extremes of pain intensity, ranging from no pain to worst possible pain. Patients indicate the point on the line that best represents their current level of pain. Similarly, the NRS asks patients to quantify the intensity of their pain on a scale of 0 to 10, with 10 being the worst possible pain. The verbal descriptive scale (VDS) asks patients to select adjectives that best describe their pain intensity, ranging from no pain to excruciating (Fig. 57-1).

Although many scales have been found to be reliable, valid, and sensitive to change in younger subjects, visual impairment, manual dexterity, and cognitive impairment may make it difficult for many elders to complete certain scales. Herr and Mobily tested five pain assessment tools in a sample of senior citizens, average age 75, who responded to an advertisement at senior citizen centers and local newspapers.12 The largest percentage of subjects perceived the VDS to be the easiest to complete (40%) and also best at describing pain (40.7%). The VAS, whether horizontal or vertical in orientation, was rated lowest in both ease of completion and describing pain. Similarly, among nursing home residents with a mean age of 85 years, and moderate dementia (average Mini-Mental State Examination score of 12 out of 30), the VDS was also the easiest to complete, with a 65% completion rate. Only 44% could complete the NRS, and 59% could complete the VAS. Although they were able to answer appropriately to qualitative yes/no questions about the presence of pain during the interview, 17% could not complete any of the quantitative scales. They also found, however, that 83% could complete at least one of the five pain assessment tools presented. Therefore, in addition to the use of large print and hearing aids, repeated questioning and the use of different tools may also help elicit responses.13

More comprehensive approaches to pain assessment with multidimensional measures also exist. For example, the McGill Pain Questionnaire (MPQ) asks for information on spatial, temporal, affective, as well as sensory qualities of pain. Although comprehensive, the questionnaire was designed and tested in the younger population. It is quite lengthy, requires basic reading and comprehension abilities, and has a large number of choices that might be difficult and overwhelming for individuals with visual and cognitive impairment. Melzack has also created a simplified version known as the SF-MPQ, which was found to be usable in older individuals. It includes descriptors representing sensory and affective components of pain. It also has measures to evaluate pain intensity such as the VAS and VDS.14

We must remember that persons with short-term memory impairment may not be able to give an accurate assessment of how their pain compared with last week, or even a few hours ago. We can only rely on the current status of pain. We need to ask caregivers to monitor and record pain symptoms, behaviors, and circumstances every few hours. Therefore, repeated questioning and the use of pain diaries or flow sheets is critical for the documentation and communication of the patient’s pain experiences, as it enables the clinician to adjust treatment and determine the overall effectiveness of the pain management program.

For severely demented patients, a structured observation of pain-related behavior is another approach to assessment. Patients with severe dementia or aphasia may communicate pain through behaviors such as crying, calling out, moaning, or guarding of the painful area. Although we cannot know with certainty if the behavior observed is indicative of pain, studies in nursing home residents with mild dementia provide some clues. The most common behaviors identified by these nursing home residents when they experienced pain included using an object for support, shift weight when seated, protect part of body that hurts, move extremely slowly, limp, lie down, and brace self when seated. Negative vocalizations included asking for pain medication, asking someone to do something to help pain, sigh/moan, patient asking himself, “why me?” talk about the pain, tell others to go away, talk more than usual, and scream. Facial expressions included sad, irritable, grimace, angry, and clenched teeth.15 The family and other caregivers are also important sources of information that can also tell about the likely meaning of such behaviors. They may be able to tell if there are changes in the resident’s routine, such as things they are now refusing to do, that may be clues to the source of discomfort.

Others have tried to develop a discomfort scale for patients with advanced Alzheimer’s disease. Discomfort was evaluated by rating observations such as noisy breathing, negative vocalization, facial expressions (e.g., content, sad, frightened, frown), or body language (e.g., relaxed, tense, fidgeting).16 Although the correct use of this assessment tool requires significant training, it is useful. While we await the further development of pain assessment tools for the cognitively impaired, we can instruct the caregiver to look for any of the behavioral responses to pain previously mentioned (Table 57-1). Because severely demented persons cannot tell what is bothering them, a careful medical evaluation and physical examination should be performed if significant changes in behaviors are observed. A careful physical examination may reveal areas of pain, inflammation, or guarding. If it is still unclear whether the person has pain or not, one could consider a trial of an analgesic such as acetaminophen with close follow-up for any changes in behavior. Careful documentation of observations in a pain diary will be helpful.

A comprehensive evaluation is extremely important in assessing the older person with pain. With increasing age, problems such as deconditioning, falls, polypharmacy, cognitive dysfunction, and malnutrition become increasingly common. Unfortunately, these conditions can also be potentially worsened by the presence of pain. Patients themselves report that pain has a significant impact on their lives. Ferrell interviewed a sample of 65 nursing home residents and asked them how pain affected their lives. Fifty-four percent reported impaired recreational activities, 53% stated that their ambulation was impaired, 45% claimed sleep disturbances, 32% felt depressed, 26% felt anxious, and 14% had a reduced appetite.3 This was corroborated by another study looking at resident assessments by nursing staff. Residents with pain were found to have a poorer functional status, more likely to have mood disturbances, and less likely to be involved in activities.6 This underscores the importance of performing a comprehensive evaluation of the older person with pain. The periodic documentation of changes in function, mood, time involved in activities, caloric intake, and sleep patterns are just as important as the documentation of pain symptoms and behaviors.

Assessment of function is important so that mobility and independence can be maximized. Information should be gathered from the history provided by the patient and caregivers. A variety of geriatric assessment tools should be used to evaluate functional status. For example, the “get up and go test” is a timed measure of the patient’s ability to rise from an armchair, walk 10 feet, turn around, walk back, and sit down again (Table 57-2). Patients are considered independent for basic transfers if they are able to complete this sequence of maneuvers in less than 20 seconds.17 Other tests are more comprehensive such as the Katz ADL scale. This scale evaluates activities of daily living such as bathing, dressing, toileting, transferring, continence, and feeding. This is done by asking whether the patient can accomplish these tasks by themselves, if they need some help, or if someone else does it for them (Fig. 57-2).18 The Lawton IADL scale is similar, and inquires about instrumental activities of daily living such as the ability to use the telephone, transportation, shop, prepare meals, do housework, laundry, take their own medications, and manage their own money (Fig. 57-3).19 If functional impairment is a concern, the care plan should include physical and occupational therapies. Such therapies can provide assistive devices to help reduce pain and improve safety, as well as teach exercises to improve walking, transfers, balance, and strength. Physical therapies also provide a variety of nonpharmacologic pain management techniques such as heat, ultrasound, and transcutaneous electrical nerve stimulation (TENS). If safety is a concern, a home visit by a visiting nurse may be necessary to assess the home environment to minimize risks of falls and injuries.

Because depression and anxiety are strongly associated with pain in the elderly,20 a psychological assessment should also be part of the evaluation. A commonly used screening instrument for depression in the geriatric population is the Yesavage Geriatric Depression Scale (GDS).21 The questions are short and simple, and require only yes or no responses.

Psychosocial factors may also contribute to the perception of pain. Older patients experience many losses in their lives, which may result in fear, anxiety, loneliness, and depression. These can affect their perception of pain and other somatic complaints. Once medical factors are addressed, involvement of a mental health professional and social worker is often useful in order to evaluate the social support networks, identify dysfunctional relationships, and determine why the person is unhappy or anxious. Sometimes these feelings are the result of interpersonal conflicts and misunderstandings with family, friends, or caregivers that can be identified and corrected. Sometimes all that is needed is reassurance, encouragement, or more social support, while others may require medication to help with their anxiety or depression. Social work staff can also be helpful in working with the family or living situation, as caregiver stress is also common. Sometimes a more structured environment (e.g., senior center, adult day health care) can reduce the risk for loneliness, depression, and anxiety. The family and other caregivers can also be enlisted to provide and reinforce nonpharmacologic and behavioral techniques that can augment medical intervention.

Guiding Principles

Many older patients experience pain daily, yet they receive inadequate analgesia. Although many older people have a higher incidence of side effects, this is not a good excuse for undertreatment. Analgesics can still be used, but should be used more wisely and cautiously. The following guiding principles and caveats have been extracted from the American Geriatrics Society Clinical Practice Guidelines, and may help maximize treatment efficacy and minimize adverse effects in the elderly.22 These principles are summarized in Table 57-3.

Principle 1: A Little Goes a Long Way

Hepatic and renal function is often reduced as a normal part of aging. This results in a higher peak plasma level, as well as a longer half-life of many drugs. For example, peak plasma levels of oxycodone are 15% greater in elderly than in younger patients. Persons with a creatinine clearance <60 may have peak plasma levels that are 20% to 50% higher. Thus elderly patients may achieve pain relief from smaller doses of analgesics than those required by younger patients. Therefore, if the pain is mild to moderate, an opioid-naïve elderly person may have a good response with a half tablet to one tablet of oxycodone or hydrocodone. Although the patient may ultimately need higher doses for adequate pain relief, the old adage “start low and go slow” accurately reflects the need for gradual and careful titration. Extra caution should be taken when converting to long-acting forms of analgesics because of the problem of drug accumulation.

Principle 2: Use Standing Doses

Medications written as pro re nata (prn) often assume that the patient knows when to take or ask for analgesics, which is not often the case, particularly in those with cognitive impairment. This often results in unnecessary suffering. If the pain is experienced at predictable times in the routine of their day, or if there are known triggers, it is better to use standing doses of analgesics to prevent pain. For example, if the person experiences pain mostly during the morning routine of getting up, but are more sedentary most of the day, the standing dose should be taken an hour before arising. If the pain is steady and continuous, analgesics should be used around the clock.

Principle 3: Be Compulsive About Assessing Pain and Side Effects

Reassessment of pain relief and side effects should be performed within hours to days, especially during initiation, titration, or after any change in analgesic medications. Adjustments may include changing the drug, dose, or timing of the medication. The assessment of side effects should be performed at the same time. Because we are working with a frailer population in whom drug accumulation occurs easily, adverse effects are more common and more devastating (e.g., confusion, falls), the importance in assessing side effects cannot be emphasized enough, especially when converting to a long-acting form of the drug.

Principle 4: Involve the Caregivers

Finally, it is important to include the primary caregivers in the treatment plans because not only are they the gatekeepers of medicines, they also watch for efficacy and side effects. We should give clear written instructions about assessment and materials that explain potential side effects of medications. Without their full understanding and cooperation, it is not uncommon for bad experiences to cause the patient or their family to fear the drug, and lead to noncompliance and needless suffering later on.

Analgesic Drugs in the Elderly

This section provides descriptions of examples of drugs to avoid, as well as those with favorable side-effect profiles for the elderly.

Acetaminophen is the drug of first choice for mild to moderate pain in the elderly. Acetaminophen can be used safely in the elderly up to 4000 mg a day, and must be used cautiously in persons with liver failure. However, there are no gastrointestinal (GI), renal, bleeding, or cognitive side effects compared with nonsteroidal anti-inflammatory drugs (NSAIDs). Acetaminophen has been demonstrated to be equally efficacious in treating osteoarthritis pain as ibuprofen, both at analgesic and anti-inflammatory doses.23

Unfortunately, NSAIDs are not as safe as acetaminophen. Common side effects include GI bleeding, renal impairment, constipation, dizziness, and confusion in the elderly. Among NSAIDs, the nonacetylated salicylate preparations such as salsalate and trisalicylate are preferred because they seem to cause less GI erosion and platelet dysfunction.24–36 Renal toxicity of NSAIDs also should be considered. Since elderly people are more dependent on prostaglandins to maintain renal blood flow, the prostaglandin-inhibiting effects of NSAIDs may reduce glomerular filtration rate and lead to significant azotemia. This adverse effect occurs most frequently among patients taking diuretics or with a history of congestive heart failure. Because creatinine clearance decreases with age, an otherwise healthy 85-year-old person most likely has a calculated creatinine clearance of <40. However, if one still decides to use NSAIDs, we recommend that it be given at half the dose, at half the frequency, and with GI prophylaxis. Patients at high risk of gastrointestinal toxicity include persons older than 60 years old, those with a prior history of ulcers or GI bleeding, or those taking corticosteroids or anticoagulation. Misoprostol (Cytotec) is recommended to prevent both gastric and duodenal ulcers caused by NSAIDs at doses starting at 100 to 200 μg twice daily. Proton pump inhibitors (Prilosec, Prevacid) are also effective, and are less likely to cause diarrhea. H2-blockers, sucralfate, or antacids are not effective in preventing gastric ulcers caused by NSAIDs.27

There is a new class of anti-inflammatory drugs known as Cox-2 inhibitors. These are reportedly less likely to cause significant bleeding and ulcers than other NSAIDs. Furthermore, they do not seem to affect platelet aggregation or interact with warfarin. However, they can cause similar kidney effects including fluid retention and edema, and some remaining Cox-1 inhibitory activity may place the gastric mucosa at risk for bleeding. Although promising, lower doses should be used until more experience is accumulated in frail elderly populations.28,29

Drugs used to treat moderate to severe pain include preparations of acetaminophen or aspirin, which are combined with opioids such as codeine (e.g., Tylenol #3), oxycodone (e.g., Percocet), hydrocodone (e.g., Vicodin), or propoxyphene (e.g., Darvon). These combinations augment the efficacy of the opioid. However, there are some preparations we prefer not to use in the elderly, as they often cause more toxicity compared with other preparations. For example, codeine seems to cause more nausea and constipation.30,31 Propoxyphene is not recommended for use in the elderly since it is no better than aspirin or acetaminophen, and has the potential for development of dependency, renal injury, as well as considerable toxicity. The use of propoxyphene can be dangerous because it interacts with antidepressants, anticonvulsants, and warfarin-like drugs to raise serum levels of these agents. Furthermore, there is also a problem of toxic metabolite accumulation. Its metabolite, norpropoxyphene, has a half-life of 30 to 36 hours and can cause PR and QRS prolongation.32 Drugs with mixed agonist-antagonist receptor activity such as pentazocine (e.g., Talwin) and butorphanol (Stadol) should never be used, as these frequently cause delirium and agitation in older persons.33

Caution should be used with tramadol (Ultram) as well. Although it is not technically an opioid, it has an efficacy similar to codeine. Its mechanism of action is on opioids, norepinephrine and serotonin receptors.34 Until there is more experience in the older population, caution should be used with higher doses, and should be avoided in persons with seizure risks and those already taking selective serotonin reuptake inhibitors or tricyclic antidepressants.

Of all the opioids used for the treatment of moderate to severe pain, morphine, oxycodone, and hydromorphone are preferred. Demerol should never be used in the elderly, because it is associated with an increased risk of delirium and seizure activity, and has a long-acting and toxic metabolite, normeperidine.35,36 Furthermore, Demerol often gets used with Vistaril to combat the problem of nausea. However, the anticholinergic activity of these drugs increases the risk of delirium.

The use of long-acting forms of opioids, such as MS Contin, OxyContin, should only be considered when the pain is stable and the opioid requirement is consistent for at least 48 to 72 hours. Because drug accumulation commonly occurs in elderly people, as a rule of thumb, one should use about 75% of the calculated 24-hour requirement when switching to the long-acting form, and cover the difference with a short-acting medication. The caveat should also be applied when switching to different opioid classes because cross-tolerance is incomplete.

Similarly, the fentanyl patch (Duragesic) should be used cautiously in the elderly. When the same doses were given to both elderly and young subjects, the serum concentrations were over two times higher in the older population.37 Although reduced amounts of subcutaneous fat may decrease the absorption of fentanyl, low protein stores associated with poor nutrition results in higher levels of free drug in the circulation. The combination of increased drug levels and decreased clearance results in more potent opioid effects in the elderly. The use of a 25-μg patch is dangerous in an elderly opioid-naïve patient and increases the risk of delirium, sedation, falls and aspiration. We advise switching to the 25-μg patch only when the morphine requirement is calculated to be consistently about 80 to 90 mg/day over the previous 48 to 72 hours.

Anticipate and Treat Side Effects

Because side effects from opioid use occur more frequently in the elderly, we need to anticipate, monitor, and treat side effects efficiently. All efforts to use the minimum effective dose should be taken. This may include the consideration of more invasive procedures (e.g., hip or knee surgery, steroid injections, or viscosupplementation), if the patient is determined to be a suitable candidate.

Constipation with opioid use is almost always inevitable in the elderly. Tolerance does not occur; therefore prophylactic use of both stool softeners and peristaltic agents is recommended. Ambulation and physical exercise also helps constipation.

Nausea is also common; however, tolerance may develop in 5 to 7 days. So for those who have trouble with nausea, smaller doses of opioids should be used initially. Patients should also be evaluated and treated for other causes of nausea (e.g., gastritis, CNS swelling, chemotherapy). If necessary, the smallest doses of metochlopramide (Reglan 5-mg tablet), prochloperazine (Compazine 5-mg tablet), or promethazine (Phenergan 12.5-mg tablet) should be used sparingly. These agents, however, are not encouraged because they have anticholinergic activity. Dehydration occurs easily in the elderly; therefore fluid intake should be monitored carefully.

Sedation is also common, but like nausea, tolerance develops after a few days. However, this could be compounded by other medications that could be adding to the sedative effects of the opioid. Because of the increased risk for automobile accidents, falls, and other accidents, patients should be evaluated for safety, and efforts toward reducing or discontinuing other sedating medications should be undertaken. If this is not possible, we recommend changing the dosing schedule to minimize administering sedating medications during the daytime. Addition of adjuvant medications may also help minimize opioid requirements. If the person does not have severe or unstable cardiac disease, one could consider a trial of Ritalin at low doses (e.g., 5 to 10 mg once or twice a day).

Delirium is more common among patients with underlying dementia. Other causes of delirium should be considered, such as medications, infections, and concurrent illnesses. Anticholinergic drugs that may be contributing to the problem should be stopped if possible. Some of the most anticholinergic drugs include diphenhydramine (Benadryl), amitriptyline (Elavil), doxepin (Sinequan), cyclobenzaprine (Flexeril), dicyclomine (Bentyl), hyoscyamine (Levsin), and trimethobenzamide (Tigan).38 Otherwise, one should use the minimum effective opioid dose, try adding an adjuvant, or consider switching to a different opioid.

Adjuvant Therapy

Neuropathic pain is opioid-resistant. Because larger doses of opioids are needed to achieve relief, the person is often better off using adjuvants such as antidepressants or anticonvulsants. There are a few antidepressants that should be avoided. Although amitripyline has been found to be very effective for neuropathic pain, it is also the most highly sedative and anticholinergic of all the tricyclic antidepressants. Doxepin and imipramine are both moderately sedating and anticholinergic. Use of secondary amines such as desipramine and nortriptyline are recommended because not only do they have the lowest incidence of sedation and anticholinergic side effects, they are effective as well. Max et al demonstrated that desipramine and amitriptyline were equally efficacious in treating diabetic neuropathy.39 In the elderly, these drugs should be started at one half to one third of the usual adult starting dose.

Anticonvulsants such as carbamazepine and valproate are both widely used and have well-established efficacy in the treatment of neuropathic pain. But two other agents might be considered early on because of their very low toxicity: clonazepam, a benzodiazepine, and gabapentin. The only major drawbacks of clonazepam are sedation and ataxia. Gabapentin is a newer anticonvulsant, which has been shown to be effective for peripheral neuropathic pain due to diabetes and postherpetic neuralgia. This drug is preferred in the elderly for several reasons: Gabapentin does not have significant interactions with commonly prescribed medications; it has few side effects; and there is no need to monitor levels. It can also be used in conjunction with low-dose tricyclic antidepressants to augment efficacy. Because it can cause dizziness, drowsiness, and ataxia, we recommend starting with doses as low as 100 mg once or twice a day, and titrating up slowly.40,41

Other adjuvants include steroids for pain from spinal cord compression, soft tissue infiltration, acute nerve compression, or brain tumors. Steroids also help nausea, anorexia, and lethargy. For bony pain from compression fractures, calcitonin nasal spray is a useful adjuvant. It can be used as a nasal spray at 200 IU every day, or given as a subcutaneous injection at 100 IU every day.42 Topical preparations include capsaicin cream. Because it depletes substance P from nerve endings, capsaicin enhances pain control when added to systemic treatment for osteoarthritis, rheumatoid arthritis, diabetic neuropathy, or postherpetic neuralgia.43–46 It also appears to be beneficial for other painful cutaneous disorders such as cluster headache, postmastectomy pain, amputation stump pain, and skin tumors.47 Unfortunately, capsaicin is often limited in use because of the initial burning it causes or the need for frequent application.

Nondrug Pain Management

Nondrug approaches are an important part of the pain management strategy in the elderly for several reasons: Nondrug strategies augment the efficacy of medications; have few adverse effects; give the patient and family a sense of participation and control; and addresses problems of functional decline, mood, and social isolation. An effective program must begin with patient and family education. The clinician should dispel misconceptions that pain, physical disability, and social isolation are normal parts of aging. There should be discussions with the patient, family, and other caregivers concerning the cause of the pain, pain assessment, medication use and side effects, goals of treatment, and use of self-help techniques such as heat, cold, massage, relaxation, and distraction.

Multidisciplinary pain clinics are an important resource in helping patients deal with the functional and psychosocial sequelae of chronic pain, instead of merely focusing on finding a magic cure. Treatments often include physical and occupational therapies, biofeedback, relaxation techniques, psychological support, and cognitive-behavioral therapy (e.g., education about coping mechanisms, stress management, communication skills). Although such programs often result in significant improvement in pain, reduction of health care utilization and less medication use,48 few elderly are actually enrolled in multidisciplinary pain clinics.49 One misconception is that older people may be less willing to participate in multidisciplinary treatment. However, studies have demonstrated that when elderly patients were offered participation in multidisciplinary pain clinics, they were as equally likely to accept participation as the younger population. Furthermore, cooperation with treatment, including the psychiatric components, was good, with dropout rates similar to the younger population.50 We need to find ways of adapting our programs to include those of similar ages and shared experiences.

Although persons with cognitive impairment may not be able to participate in some of the more cognitive therapies, there are strategies that can be used even among persons with dementia. Exercise is one of the most important interventions. Although many older people assume that exercise is an activity for younger persons, exercise in older persons has been shown to have many benefits, including reduction of pain symptoms and amelioration of depression. In a study of community dwelling persons older than 60 years old with self-reports of pain, physical disability, and radiographic evidence of osteoarthritis, enrollment in an exercise program was clearly better than education in relieving pain. Both aerobic and resistance exercises resulted in modest improvements in physical disability, pain, and objective measures such as improved time to climb or descend stairs, and greater walking distances in a timed 6-minute walk.51 Not only does exercise reduce contractures, weakness, fatigue, recurrent falls, and help with problems such as insomnia and constipation, it also can improve appetite, reduce depression, and improve self-esteem. Furthermore, exercise has the benefit of slowing bone loss in women with postmenopausal osteoporosis.52 Emphasis on attainable goals rather than on pain symptoms during exercise results in improved mood, less fatigue, increased capacity in most functional tasks, and less perception of pain.53 Understandably, the exercise program should be adapted to each person’s ability and safety. Compliance is improved if low-tech, inexpensive, and simple exercises are emphasized, group socialization is provided, and personal exercise equipment is available such as stationary cycles and free weights. Guidelines for exercise prescriptions are shown in Figure 57-4.

Physical modalities should be employed in the treatment of musculoskeletal or soft tissue pain. Examples include use of heat, cold, and manipulation and massage. Because heat and ice can be self-applied, they give patients some control over their symptoms and treatments. However, precautions must be taken to avoid thermal burns.

Another effective behavioral intervention for those with cognitive impairment is distraction. Examples of distraction techniques include music, conversation, and activity involvement. Ensuring adequate nutrition and sleep will also help make the pain more bearable, and perhaps actually less intense as a sensory experience.

We must remember that success is relative. Goals are often different in the older population. The goal of care in the elderly is usually not return to work or prolongation of life, but maximization of quality of life. This might include goals such as being able to walk 100 feet independently, being able to play bingo or bridge every day, or being able to attend religious services on a regular basis. Although improvements may not necessarily be as dramatic as in the younger population, minimal improvements in pain, mood, functional capacity, or activity involvement may lead to large gains in quality of life.