Perry G. Fine, M.D.
Professor, Department of Anesthesiology and
Associate Medical Director, Pain Management Center, University of Utah,
National Medical Director, VistaCare
Member, American Geriatrics Society Panel on Chronic Pain in Older Persons
fine@aros.net

Introduction

The fastest growing segment of the U.S. population are those individuals who are 85 years of age and older.¹ It is estimated that 25-50% of community-dwelling older people experience substantial pain on a regular basis and about one in five are taking analgesic medications regularly. Older people are more likely to suffer chronic pain from arthritis, bone and joint disorders, back problems, and neuralgias, along with all the other chronic conditions that typically cause pain. The consequences of unrelieved chronic pain in this population, similar to others, include depression, decreased socialization and sleep disturbance. It is now recognized that pain is greatly under-recognized, no less under-treated, in the older population.^2,3

Unique to older individuals is the interactional, or synergistic, nature of chronic pain superimposed upon other commonly occurring co-existing diseases and chronic conditions (i.e., CAD, COPD, Alzheimers and other dementias, Parkinsonās, osteopenia, etc.). This leads to increased debility and morbidity from decreased ambulation, deconditioning, and the additive effects of multiple drug prescriptions. For all these reasons, it is extremely important that all Anesthesiologists recognize the frequency, consequences and management challenges of chronic pain in this population. For those who serve as chronic pain management consultants, these patients' unique characteristics need to be thoroughly understood in order to provide the greatest benefit to them.

Assessment

Understanding and validation of a patientās pain complaints through the process of thorough assessment is fundamental to the good practice of medicine. Management of pain should always address specific pathophysiology whenever possible.⁴ Other than the usual components of a comprehensive pain evaluation, key points to focus on during assessment in aging patients include:

1. recognition that words such as "burning", "discomfort", "aching", "soreness", and other terms may be substituted for Īpainā, per se.
2. cognitive and language impairments are common, necessitating interpretation of nonverbal and vocalized pain behaviors, as well as eliciting a history of recent changes in function, as indicators of pain.
3. detailed evaluation of activities of daily living (ADLs) and performance measures of function.
4. Influence of chronic pain on mood and psychosocial function, utilizing age-specific scales (e.g., geriatric depression scale).
5. chronic medical conditions and medication use which influence chronic pain and treatment alternatives.

Principles of Management

An integrated treatment plan that incorporates pharmacotherapy, nonpharmacologic interventions and functional rehabilitation should be considered for all patients who have debilitating chronic pain.⁵ For the purposes of this review, Anesthesiologists need to have a thorough understanding of pharmacologic therapy. Nerve blocks, and other invasive procedures have a place in selected cases, but over the long run, the vast majority of patients will benefit from thoughtfully applied medication management. The underlying principles to this approach are summarized below.⁶

1. All older patients with diminished quality of life as a result of chronic pain are candidates for pharmacologic therapy.
2. The least invasive route of administration should be used.
3. Fast-onset, short-acting analgesic drugs should be used for episodic pains.
4. Acetaminophen is the drug of choice for relieving mild to moderate musculoskeletal pain. The maximum dosage of acetaminophen should not exceed 4,000 mg per day.
5. Nonsteroidal antinflammatory drugs (NSAIDs) of the cyclo-oxygenase type 1 class (COX-1) should be used with extreme caution.
6. Opioid analgesic drugs may be helpful for relieving moderate to severe pain (Table 1).
7. Drug titration should be conducted slowly and carefully, with close monitoring for adverse effects.
8. Drug-related constipation should be anticipated and prevented.
9. Non-opioid analgesic medications may be appropriate for some patients with some chronic pain syndromes, especially neuropathic pain (Table 2).

References:

1. Projections of the Population of the United States: 1977 to 2050. Current Population Reports, Series P-25, No. 74. Washington, D.C., U.S. Bureau of the Census, 1977
2. Helme RD, Gibson SJ. Pain in the elderly. In: Jensen TS, Turner JA, Wiesenfeld-Hallin Z, eds. Proceedings of the 8^th World Congress on Pain: Progress in Pain Research and Management, Vol. 8. Seattle, IASP Press, 1997, pp 919-944
3. Mobily PR, Herr KA, Clark MK, Wallace RB. An epidemiologic analysis of pain in the elderly. The Iowa 65+ Rural Health Study. J Aging Health 1994;6:139-145
4. Nishikawa ST, Ferrell BA. Pain assessment in the elderly. Clin Geriatr Issues Long Term Care 1993;1:15-28
5. Ferrell BR. Patient education and nondrug interventions. In: Ferrell BR, Ferrell BA, eds. Pain in the Elderly. Seattle, IASP Press, 1996, pp 35-44
   
6. AGS Panel on Chronic Pain in the Older Persons. The management of chronic pain in older persons. JAGS 1998;46:635-651

Table 1: Opioid Analgesic Drugs
(click here)

Table 2: Non-Opioid Drugs for Pain Management
(click here)