CHAPTER 67: Pain in the Elderly

INTRODUCTION

It is well known that we are an aging society with 20% of the population reaching 65 years or older by the year 2030.¹ Older Americans have more chronic conditions such as osteoarthritis, atherosclerosis, cancer, and diabetes, contributing to increased health care costs, one-third of the total annual health budget today. In the older patient population, pain is the most common symptom noted when consulting a physician.² There are multiple sites and causes of these painful conditions, including lower back (40%), arthritis (24%), previous fractures (14%), and neuropathies (11%).³

Despite the well known association of aging and chronic painful conditions, pain remains underreported and undertreated. Reasons for undertreatment are related to fear, bias, and education from health care providers (HCPs) and from patients themselves. Patients often believe that pain is inevitable, a normal part of aging, and they fear adverse effects from treatment. They are apprehensive about underlying cancer and addiction to analgesics. Health professionals may mistakenly believe that older patients have a higher pain tolerance and fail to inquire about pain. Many of the chronic conditions manifesting pain in older patients are not curable; however, there must be a focus on the management of the pain associated with these chronic conditions.

The American Geriatrics Society and American Medical Directors Association have published guidelines for the assessment, treatment, and monitoring of chronic pain in older patients, advocating individualized pain management, which is vital to patients with multiple underlying chronic diseases.^4,5 A number of treatment modalities have been demonstrated to be effective for older persons. Pharmacologic and nonpharmacologic options should be considered in the context of the patient's beliefs, goals, and desires. Combining these options helps keep drug effects lower.⁶ With advancement in research and newer treatment options, regimens can target chronic pain while addressing comorbid conditions specific to the older patient.

This chapter will explore pain in the older patient. We address the neurophysiology, assessment of pain in cognitively intact and non-intact patients, and psychosocial issues associated with pain in this clinical population. Traditional treatments including pharmacologic and nonpharmacologic treatments are discussed; complementary and alternative methods for pain treatment, as well as extended care facilities and pain at the end of life, are also reviewed.

PAIN AND AGING

Age-related functional, structural, and biochemical changes of the pain pathways have been reported.⁷ The effects of age on the human brain are extensive, involving changes in structure, neurochemistry, and function.⁸ Excitatory and inhibitory mechanisms in the nervous system exert differential effects that contribute to the experience of pain and depend on complex communications among neural systems. There is strong evidence of progressive, age-related loss of serotonergic and noradrenergic neurons in the dorsal horn, suggesting impairment of the pain inhibitory system.^9,10 Functional consequences of structural age-related changes are difficult to extrapolate because of the highly ...