What causes pain in the elderly client? The causes are as varied as the clients themselves. Pain may be an acute phenomenon associated with trauma, injury, illness, or surgery. Age-related changes in visual acuity, hearing, mobility, balance, and judgment increase the elderly client’s propensity for accidents and traumatic injury.

Loss in body mass—muscular, fatty, or subcutaneous tissue—results in the potential for more severe injury than for younger clients in the same traumatic instance. Osteoporosis, a loss of bone density, results in the potential for fractures. Subcutaneous tissue loss often results in fine, tissue-paper-thin skin that is easily torn. Even slight dehydration causes changes in skin turgor, which can result in easier or more extensive injury.

Injuries to the skin, subcutaneous tissues, muscles, tendons, ligaments, or bones may result in an inflammatory response, mediated by
the immune system. Breaks in the skin or mucous membranes are potential avenues for the development of infection. Infections also result in immune and inflammatory responses. Chemical mediators of the inflammatory response are also chemical mediators in the pain process, so elderly clients at risk for these problems are at increased risk for pain. Normal changes in the aging process do not involve a breakdown or weakening of the immune system, so inflammation continues to be a natural response to injury in the elderly client.

Manifestation of pain may occur or change with vascular changes associated with aging. Anginal pain or intermittent claudication may accompany arterial insufficiency related to atherosclerosis or hypertension. Peripheral neuropathies may reduce or completely inhibit the sensation of pain in the affected extremities, thus restricting the protective mechanisms associated with pain. Neuropathies are frequently associated with venous changes, diabetes mellitus, or use of certain neurotoxic medications. Peripheral neuropathies are generally not reversible. Pain sensation may be masked by the use of prescribed or over-the-counter medication. Many elderly clients use pain medication for chronic conditions such as osteoarthritis. Even the use of aspirin as a cardioprotective may reduce the pain response. For this reason, it is very important to document a comprehensive medication history when assessing an elderly client for pain.

Multiple medical conditions that occur more commonly as the client ages are related to increased incidences of pain. Chronic conditions, including osteoarthritis, result in pain that may significantly affect the elderly client’s quality of life and is responsible for self-medication as well as increased visits to the doctor or nurse practitioner. Cancers are more common in the elderly client as well. With improvements in treatment and detection
of many types of cancer, the associated pain is often in the chronic phase of the illness. Pre-existing or chronic illnesses may mask manifestations of acute pain or delay appropriate intervention for acute pain.

Frequent interface with the healthcare professional is yet another reason for the experience of pain for the elderly client. Painful diagnostic procedures, surgical procedures, treatments, and rehabilitation all account for instances of iatrogenic pain. Prior to certain invasive procedures, medications used for the treatment of chronic pain that interfere with blood clotting, such as NSAIDs or aspirin, must be curtailed. It is important to be proactive in identifying alternate pain relief interventions appropriate for the client to use in the absence of his or her usual relief measures.

Routes of administration should be carefully considered in relation to age-related changes. Oral routes can be affected by changes in swallowing ability, changes in the amount of oral secretions, and changes in digestion. Carefully assess the client’s ability to swallow tablets. If swallowing is a problem, consider breaking the tablet into smaller pieces or crushing it to administer it with thickened liquids such as applesauce or dissolved in water or juice. Tablets that are designed for timed release or with enteric coatings should not be broken or crushed. Many medications are available in liquid or suspension forms as an alternative to tablets.

To assist the client in swallowing tablets, have him or her sit upright if possible. Place the tablet at the front of the tongue for better control.
If the tablet is placed at the back of the mouth, it is sometimes more difficult to swallow. Swallowing is easier with only one tablet at a time. Clients who take multiple medications at one time often attempt to swallow them all at once. This practice could result in aspiration or choking for the client who has difficulty swallowing. After administering pills to an elderly client, examine the mouth to assure they have been swallowed. This could prevent choking later, in addition to making certain that the medicine will not be found on the floor or in the bedding later.

Clients who are dehydrated or complain of a dry mouth (such as elderly clients on antihypertensive medications or diuretics) may complain of difficulty swallowing pills because they “stick” to the oral mucosa. Giving the client a small sip of juice or water prior to giving the pills frequently helps with this complaint. Clients with hiatal hernias or acid reflux often complain that pills cause an increase in discomfort. Reduced stomach motility may interfere with timely absorption of medication taken orally.

Sublingual (medication placed under the tongue) or transbuccal administration—medication absorbed across the buccal membrane (mucous membranes under the tongue or between the gums and cheek)—can be problematic because of dry mouth, fragile membranes, dentures, or poor circulation. Clients with a dry mouth, which may occur as a natural change in aging or from medications or medical conditions, may experience difficulty with medications administered via this route. Insufficient moisture may slow or prevent the tablet from dissolving. The tablets may become stuck or may damage already fragile mucous membranes. Damage to the oral mucous membranes will result in pain and inflammation. Inflammation will interfere with transbuccal absorption.

Dental appliances may get in the way of tablet placement. Tablets may also become caught under dentures, causing injury. Some medications are now available as sprays for transbuccal administration. Finally, in the elderly client with swallowing difficulties and/or mentation changes,
placement of pills under the tongue or between the gum and cheek may present an aspiration hazard.

Transcutaneous or transdermal absorption of medication may be affected by more rapid metabolism, thinning of skin or subcutaneous tissue, or poor circulation. Many pain management medications are prescribed for elderly adults using this route, including nitropaste and fentanyl. Clients who are febrile will absorb and metabolize medication across the skin more quickly. This results in poor pain relief prior to the next administration. Loss of subcutaneous tissue or poor peripheral circulation causes poor absorption and movement of the medication into circulation.

When placing transdermal medication on elderly clients, choose a spot on the trunk, avoiding the limbs. Monitor the client for fever. Assess the area of placement for pallor or mottling, signs of poor circulation. Avoid scarred areas or open areas, such as skin tears or abrasions.

Subcutaneous injection is an option with similar drawbacks for use in the elderly population. Loss of subcutaneous tissue reduces areas for the medication to deposit. Changes in peripheral circulation may reduce transport of the medication into systemic circulation, reducing effective pain control. Careful assessment of the injection site for symptoms of circulatory compromise, including atrophy, pallor, and mottling, will reduce some of the transport problems. Choosing a site for injection on the trunk, especially the abdomen (avoiding the umbilicus or any areas of varicosity), is also beneficial to improve pain control.

Some specific advantages to using subcutaneous injection include the fact that the needle is small and fine, making a relatively painless
injection technique. Bruising or bleeding are infrequent complications. This form of administration is a technique that can readily be taught to clients and their families.

Intramuscular injection is problematic in the elderly client who has lost muscle tissue to atrophy, wasting, or loss of body mass. Careful choice of site should consider the volume of medication to be injected, as decreased muscle mass reduces the area for storage or deposit of medication. Atrophy caused by circulatory insufficiencies is a good indicator that transport of the injected medication to central circulation will be poor. Finally, intramuscular injections may be extremely painful, especially when administered to a muscle that is not in a state of relaxation. Proper positioning and relaxation techniques are good aids to preventing muscle tension.

Rectal administration is often a reasonable choice when the oral route is not a possibility for reasons such as nausea and vomiting or difficulty swallowing. Some particular considerations when using this route for the elderly client include comfort, safety, bowel habits, and cardiac history. Suppositories are made up of inert solid material that melts, such as glycerin, allowing the medication to be absorbed across the rectal mucosa. The suppository must be retained in the rectal vault long enough for melting and absorption. Clients suffering from diarrhea or rectal irritation may not be able to resist the urge to defecate, thus expelling the suppository before the medication is absorbed. Clients with hemorrhoids often complain of intense discomfort when suppositories are inserted. Elderly clients may have difficulty lying in a position to facilitate insertion. Using the rectal route for self-administration of pain medication is repellent to some clients. Peripheral neuropathies or osteoarthritis diminish manual dexterity, making handling the suppository and insertion difficult. Stimulation of the vasovagal response when medication is inserted rectally is potentially dangerous to clients with a cardiac history. Even absent of a history of cardiac problems, vagal stimulation may result in a drop in cardiac rate and blood pressure, resulting in syncope.

Assess the elderly client carefully before using this route, and provide safety measures, including protection from falls and other consequences of syncope, as well as ready access to a bathroom, commode, or bedpan
should the rectal insertion stimulate a strong urge for a bowel movement. It is important to know that colostomy stomas can be used for insertion of rectal medication. Absorption across the mucous membranes of ileostomy or urinary diversion stomas is less certain, primarily because of the consistent nature of the drainage.