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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
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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.
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History and
Physical Examination
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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 ...