Pain Management   18  

Ann L. Horgas, Mindy S. Grall, and Saunjoo L. Yoon

OVERVIEW

Pain is a common experience among older adults. The prevalence of persistent pain in older adults ranges from 25% to 76% among community-dwelling elders and from 83% to 93% among nursing home residents (Abdulla et al., 2013). Across all care settings and most specialty areas, nurses interact with older adults. By the year 2030, it is projected that there will be 72.1 million adults 65 years of age or older, representing 19% of the U.S. population, and those older than 85 years represent the fastest growing segment of the population (www.aoa.gov/Aging_Statistics). The Centers for Disease Control and Prevention reported that, in 2010, 13.6 million adults older than 65 years had been discharged from an acute care hospital and 298.4 million had at least one visit to an ambulatory care setting (Federal Interagency Forum on Aging-Related Statistics, 2012). Thus, care of older adults extends across many settings, and nurses in acute care settings also need to be knowledgeable about the most effective strategies for assessing and managing pain in this population (Herr, 2010).

There is a substantial body of literature that documents the high prevalence of pain in the U.S. older adult population (Institute of Medicine [IOM], 2011). Chronic diseases, including cardiovascular disease, diabetes mellitus, degenerative joint disease, osteoporosis, cancer, and peripheral neuropathies, are more prevalent in older adults and are often associated with persistent pain (Bruckenthal, 2010). In a study of a nationally representative sample of older adults with cancer receiving community-based hospice care, Herr et al. (2012) reported that pain was present in 83% of the population. These data highlight the need for increased knowledge of appropriate interventions to prevent and control pain in the elderly population.

Older adults commonly experience multiple causes and types of pain (Patel, Guralnik, Danise, & Turk, 2013). Acute pain is typically associated with surgery, fractures, or trauma (Herr, Bjoro, Steffensmeier, & Rakel, 2006). Persistent pain (i.e., pain that continues for more than 3–6 months) is most frequently associated with musculoskeletal conditions such as osteoarthritis (The American Geriatrics Society [AGS] Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). In 2010, it was estimated that more than 19 million surgeries were performed on older adults, including 2.29 million musculoskeletal surgeries (including knee and hip replacements; Federal Interagency Forum on Aging-Related Statistics, 2012). In the acute care setting, older adults are therefore likely to have acute pain superimposed on persistent pain, particularly when admitted for a surgical procedure or acute illness.

Untreated or ineffectively treated moderate to severe persistent pain has major implications for older adults’ health, functioning, and quality of life (Herr, 2011). Pain is associated with depression, social withdrawal, sleep disturbances, impaired mobility, decreased activity engagement, and increased health care use (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). Other geriatric conditions that can be exacerbated by pain include falls, cognitive decline, deconditioning, malnutrition, gate disturbances, and slowed rehabilitation (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). In the hospital setting, older adults suffering from acute pain have been reported to be at increased risk for thromboembolism, hospital-acquired pneumonia, and functional decline (Wells, Pasero, & McCaffery, 2008). Pain can also increase caregiving burdens for family members, who must often assist with treatments to alleviate pain at home (Herr, 2011). Pain also contributes to increased health care resource utilization and costs (IOM, 2011). Given the implications of unrelieved pain on the quality of life and health care use among older adults, it is not surprising that the IOM (2011) declared chronic pain a public health problem in the United States.

Over several recent decades, significant clinical and empirical efforts have been undertaken to improve the assessment and management of pain in older adults. Beginning in 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in the United States mandated pain assessment and management as part of the hospital survey and accreditation process (JCAHO, 2001). This accrediting body asserted that patients “have the right to appropriate assessment and management of pain” and declared pain as the fifth vital sign (JCAHO, 2001). This mandate exposed some of the challenges associated with assessing and managing pain in older adults in general, and in persons with dementia in particular. This, in part, spurred clinical and research activity to develop measures for assessing pain in older adults, particularly those with cognitive impairment. These behavioral measures have been reviewed in several published reports (Herr, Bursch, Ersek, Miller, & Swafford, 2010), including a comprehensive chapter focusing specifically on pain assessment tools in the classic reference by Pasero and McCaffery (2011). In addition, multiple clinical guidelines have been developed by leading scientific and clinical organizations, including the AGS (2009; Hadjistavropoulos et al., 2007), American Pain Society (Hadjistavropoulos et al., 2007), and the American Society for Pain Management Nursing (Herr, 2011). In 2011, the IOM convened a conference on pain care to evaluate the adequacy of pain assessment, treatment, and management, and to identify barriers to appropriate pain care in the United States. The ensuing report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, comprehensively addresses the public health problem of chronic pain and the challenges of pain management (IOM, 2011). The report provided a blueprint for transforming the way pain is understood, assessed, treated, and prevented and delineated recommendations and objectives for researchers, practitioners, educators, and policy makers to facilitate the transformation of pain care. Among the key IOM recommendations are enabling self-management of pain, eliminating barriers to adequate pain care and disparities in assessment and treatment among high-risk groups, including older adults, and promoting interdisciplinary research and training for those who are conducting research on pain. Furthermore, the Affordable Care Act required a new focus on pain research at the National Institutes of Health (NIH) by directing it to continue and expand, through the Pain Consortium, an aggressive program of basic and clinical research on the causes of and potential treatments for pain. The NIH Pain Consortium enhances pain research and promotes collaboration among researchers across the many NIH institutes and centers that have programs and activities addressing pain. Most recent, the Gerontological Society of America (GSA), a major interdisciplinary organization promoting aging research, published a comprehensive monograph focusing on pain in the elderly population. The From Policy to Practice monograph, titled An Interdisciplinary Look at the Potential of Policy to Improve the Health of an Aging America: Focus on Pain, analyzes current policy initiatives aimed at improving pain care among older adults in America (GSA, 2014). Taken together, these initiatives highlight the attention that is being focused on improving pain care among older adults. Despite these efforts, there is persistent evidence that pain management for older adults in general, and specifically for those with dementia, remains suboptimal across care settings (Herr, 2011; Horgas, Elliott, & Marsiske, 2009, Titler et al., 2009). This chapter provides the best evidence on the assessment and treatment of pain in older adults, especially those with cognitive impairment. The goal is to provide information here that can be used to establish, implement, and evaluate protocols in the acute care setting that will improve pain management for older adults.

ASSESSMENT OF PAIN

Pain is defined as a complex, multidimensional subjective experience with sensory, cognitive, and emotional dimensions (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Melzack & Casey, 1968). For clinical practice, Margo McCaffery’s classic definition of pain is perhaps the most relevant. She states, “Pain is whatever the experiencing person says it is, existing whenever he says it does” (McCaffery, 1968, p. 95). This definition serves as a reminder that pain is highly subjective and that patients’ self-report and description of pain is paramount in the pain assessment process. This definition, however, also highlights the difficulty inherent in pain assessment. There is no objective measure of pain; the sensation and experience of pain are completely subjective. As such, there is a tendency for clinicians to doubt patients’ reports of pain. Pasero and McCaffery (2011) provided a comprehensive chapter on biases, misconceptions, and misunderstandings that hampered clinicians’ assessment and treatment of patients who reported pain. These issues apply to patients across the life span, and led the authors to conclude the following:

Among older adults, there is persistent evidence that pain is underdetected and poorly managed (Herr, 2011; Horgas et al., 2009). There are a number of factors that contribute to this situation, including individual-based, caregiver-based, and organizational-based factors. Individual-based factors that may impair pain assessment include the following: (a) belief that pain is a normal part of aging, (b) concern of being labeled a hypochondriac or complainer, (c) fear of the meaning of pain in relation to disease progression or prognosis, (d) fear of narcotic addiction and analgesics, (e) worry about health care costs, and (f) a belief that pain is not important to health care providers (AGS Panel on Persistent Pain in Older Persons, 2002). In addition, cognitive impairment is an important factor in reducing older adults’ ability to report pain (Horgas et al., 2009; Lukas et al., 2013).

Pain detection and management are also influenced by provider-based factors. Health care providers have been found to share the mistaken belief that pain is a part of the normal aging process and to avoid using opioids because of fear about potential addiction and adverse side effects (Pasero & McCaffery, 2011). Similarly, cognitive status influences providers’ assessment and treatment of pain. Several studies have documented that cognitively impaired older adults were prescribed and administered significantly less analgesic medication than were cognitively intact older adults (Horgas & Tsai, 1998; Morrison, Magaziner, Gilbert, et al., 2003). This finding may reflect cognitively impaired adults’ inability to recall and report the presence of pain to their health care providers. It may also reflect caregivers’ inability to detect pain, especially among frail older adults. Health care providers should face the challenge of pain assessment by first systematically examining their own biases, beliefs, and behaviors about pain, and eliciting and understanding the challenges and beliefs their patients bring to the situation as well (Pasero & McCaffery, 2011).

Self-Reported Pain

Patients’ self-report is considered the gold standard for pain assessment (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Herr, 2011). There is no objective biological marker or laboratory test for the presence of pain. Diagnostic tests, however, often can reveal clinical problems, such as infection or inflammation, that may be associated with pain. The first principle of pain assessment is to ask about the presence of pain at regular and frequent intervals (Pasero & McCaffery, 2011). It is important to allow older adults sufficient time to process the questions and formulate answers, especially when working with cognitively impaired older adults. It is also important to explore different words that patients may use synonymously with pain, such as discomfort or aching. Use open-ended questions, such as “Tell me about your pain, aches, soreness, or discomfort,” to elicit information about pain from older adults (Herr, 2011).

Pain intensity can be measured in various ways. Some commonly used tools include the numerical rating scale (NRS), the verbal descriptor scale, and the Faces scale (Herr, 2011). The NRS is widely used in hospital settings. Patients are asked to rate the intensity of their pain on a 0 to 10 scale. The NRS requires the ability to discriminate differences in pain intensity and may be difficult for some older adults to complete. A recent study confirmed that the NRS was a reliable and valid tool for measuring pain and distress in community-residing elders (Wood et al., 2010). However, the authors reported a significantly higher failure rate in completing the NRS among those older than 81 years (11.1% failure rate) compared to those in the 61 to 70 (5.5% failure rate) or 71 to 80 (7.8% failure rate) age groups. This study also provides important information about the reliability of NRS ratings over time, a key factor in assessing treatment effectiveness and changes in pain ratings over time. Wood et al. (2010) reported that NRS current pain ratings has a reliability coefficient of .85, indicating high measurement reliability. There is evidence that older adults prefer a vertical orientation to the NRS when presented on paper (Herr, 2011).

The verbal descriptor scale, however, has been specifically recommended for use with older adults (Herr, 2011). This tool measures pain intensity by asking participants to select a word that best describes their present pain (e.g., no pain to worst pain imaginable). This measure has been found to be a reliable and valid measure of pain intensity and is reported to be the easiest to complete and the most preferred by older adults (Herr, 2011; Herr, Bjoro, & Decker, 2006). The Faces Pain Scale (FPS), initially developed to assess pain intensity in children, is often used to measure pain intensity, especially among cognitively impaired older adults. The FPS and the FPS–Revised (FPS-R) consists of facial expressions of pain, ranging from the least pain to the most pain possible (Herr, Bjoro, & Decker, 2006). Among adults, the FPS is considered more appropriate than other pictorial scales because the cartoon faces are not age, gender, or race specific. There is some evidence that cognitively impaired African American and Hispanic individuals prefer faces scales to numerical scales, possibly because of the impact of culture on pain expression (Herr, 2011). However, other studies suggest that the FPS has lower reliability and validity when used among older adults with cognitive impairment (Herr, 2011). See the Resources section for information on accessing these measurement tools.

Observed Pain Indicators

Dementia compromises older adults’ ability to self-report pain. In patients with dementia, and other patients who cannot provide self-report, other assessment approaches must be used to identify the presence of pain. According to the American Society for Pain Management Nursing consensus statement on assessing pain in nonverbal patients, a hierarchical pain assessment approach is recommended (Herr, Coyne, et al., 2006). The four steps in the hierarchical process are as follows: (a) attempt to obtain a self-report of pain; (b) look for an underlying cause of pain, such as surgery or a procedure; (c) observe for pain behaviors; and (d) seek input from family and caregivers (Herr, Coyne, et al., 2006; Wells et al., 2008). If any of these steps are positive, the nurse should assume that pain is present and a trial of analgesics can be initiated. Pain behaviors should be observed before and after the analgesic trial in order to evaluate whether the analgesic was effective or if a stronger dose is needed.

Observational techniques for pain assessment focus on behavioral or nonverbal indicators of pain (Hadjistavropoulos et al., 2007; Herr, 2011; Herr, Coyne, et al., 2006; Horgas et al., 2009). Behaviors, such as guarded movement, bracing, rubbing the affected area, grimacing, painful noises or words, and restlessness, are often considered pain behaviors (AGS, 2006; Horgas et al., 2009). In the acute care setting, vital signs are often considered as physiological indicators of pain. It is important to note, however, that elevated vital signs are not considered a reliable indicator of pain, although they can be indicative of the need for pain assessment (Herr, Coyne, et al., 2006; Pasero & McCaffery, 2011).

Over the past few decades, approximately 20 different observational measurement tools have been developed to assess behavioral indicators of pain. These tools differ in their content, comprehensiveness, and scoring. Some have been tested empirically and show utility, but many require further psychometric testing of reliability and validity before they can be recommended for widespread use. (Herr, 2011). There is no perfect behavioral measure of pain that can be universally applied in all settings or with all nonverbal people. However, a recent team of experts developed a consensus statement for the use of pain behavior assessment tools in nursing homes (Herr, 2010). The panel recommended the Pain Assessment in Advanced Dementia (PAINAD) scale (Warden, Hurley, & Volicer, 2003) and the Pain Assessment Checklist for Seniors With Severe Dementia (PACSLAC; Fuchs-Lacelle & Hadjistavropoulos, 2004). A comprehensive review of these measures, as well as other similar tools, is available on the City of Hope website (see the Resources section). In addition, the Hartford Institute for Geriatric Nursing provides online resources for pain assessment in older adults with dementia that include information on the PAINAD tool, and an instructional video on how to use it (see the Resources section for link). Several caveats about observational tools must be noted: (a) the presence of these behaviors is suggestive of pain but is not always a reliable indicator of pain and (b) the presence of pain behaviors does not provide information about the intensity of pain (Pasero & McCaffery, 2011). As such, pain behavior tools should be used as one part of a comprehensive pain assessment.

In summary, pain assessment is a clinical procedure that can be hampered by many factors. Systematic and thorough assessment, however, is a critical first step in appropriately managing pain in older adults. Assessment issues are summarized in the recommended pain management protocol. The use of a standardized pain assessment tool is important in measuring pain. It enables health care providers to document their assessment, measure change in pain, evaluate treatment effectiveness, and communicate to other health care providers, the patient, and the family. Comprehensive pain assessment includes measures of self-reported pain and pain behaviors. Information from family and caregivers should also be obtained, although these data should be considered supplemental rather than definitive.

INTERVENTIONS AND CARE STRATEGIES

Managing pain in older adults can be a challenging process. Many older adults suffer from comorbidity and frailty, which may complicate the management of their pain. Balancing the treatment for multiple comorbidities that can either cause or contribute to pain is especially challenging (Fine, 2012). As people age, the incidence and prevalence of illnesses that cause pain increase. These include rheumatological diseases, cancer, cardiac disease, postherpetic neuralgias, inflammatory diseases, and peripheral vascular diseases (Kaye, Baluch, & Scott, 2010). Additionally, it can be difficult to treat pain in older adults with an underlying dementia, as cognitively impaired adults often cannot self-report their pain.

The main goal in the management of pain in older adults is to maximize function and quality of life by minimizing pain to the extent possible (Herr, 2010; Wells et al., 2008). Pain relief is noted to be one of the most common goals of older adults (Makris, Abrams, Gurland, & Reid, 2014). There is a consensus supporting a multimodal approach to the management of pain, including pharmacological and nonpharmacological therapies (Makris et al., 2014). Pharmacological interventions are an integral component of pain management in older adults (Pasero & McCaffery, 2011). However, consideration must be given when devising a medication treatment plan given the physiological changes in older adults, which may both contribute to pain and be affected by pain treatments (Kaye et al., 2010). This means that the selection of pharmacological therapies must include a risk-and-benefit analysis taking into account the potential benefits versus the potential negative effects of pain medications on cognition and each organ system. It should be emphasized that pharmaceutical pain management is often more imperative in older adults with dementia because their ability to participate in nonpharmacological pain management strategies may be limited by their cognitive capacity (Buffum, Hutt, Chang, Craine, & Snow, 2007).

Barriers to pharmacological pain management should be noted. These can stem from both provider and patient perspectives. Patients often do not report pain for myriad reasons, including their expectation that pain is a normal part of aging, the desire to avoid testing, and not wanting to add medications to their regimens (Fine, 2012). Prescribers may also pose barriers, including the fear of stricter regulations surrounding the prescribing of opioids and potential concerns for diversion (Fine, 2012). Unfortunately, the result of these independent and/or combined barriers can lead to the undertreatment of pain in older persons, both with and without dementia.

When choosing pain strategies, consideration should be given to severity of pain because moderate and severe pain often require different modalities in order to provide adequate pain relief. In addition, nociceptive pain requires different pharmacological agents than neuropathic pain. It is also important to recognize the dangers in selecting potentially inappropriate medications (PIMs) for the treatment of pain in older adults. Medication-related problems can be costly and lead to poor outcomes (Campanelli, 2012). The AGS provides a list of PIMs, known as the Beers Criteria for PIMs, and updates this list regularly. Using an expert review panel, Beers et al. developed the original list of PIMs in 1991, which identified medications that had an “unfavorable balance of risk and benefits” (Campanelli, 2012, p. 2). This list has been updated and expanded several times, most recently in 2012. The intent of the Beers Criteria is to provide guidelines for the appropriate selection of medications while facilitating the education of clinicians and patients on proper drug use. Clinicians prescribing pain medications to persons aged 65 years and older should use the Beers Criteria to help identify medications that may have a greater risk-to-benefit ratio (Campanelli, 2012).

Several additional excellent pain management guidelines and protocols have been developed for use in the management of pain in older adults. For instance, the AGS updated their clinical practice guidelines for managing persistent pain in older adults (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). The consensus statement by the World Health Organization (WHO) on the use of Step III opioids for chronic, severe pain in older adults provides detailed guidelines pertaining to the assessment of pain and use of opioids for cancer and non-cancer-related pain in 2008, and is due to be updated soon (Pergolizzi et al., 2008). In addition, there are other published guidelines for the assessment and management of pain in specific diseases, such as osteoarthritis (Hochberg et al., 2012). Pasero and McCaffery (2011) also provide one of the most comprehensive guides for pain management, including an updated edition that addresses pain management in older adults. Although there is a paucity of clinical practice guidelines for the management of pain in persons with dementia, there is strong support in the literature regarding the effects of untreated pain on persons with dementia (Corbett et al., 2014). In order to ensure that pain is treated in older persons with dementia, Corbett et al. (2014) provide guidance and recommendations for the treatment of pain in this population using multimodal approaches. See the Resources section for more information on accessing these items.

Pharmacological Pain Treatment

The management of pain in older adults can be optimized by using a multimodal approach. This includes the use of pharmacotherapy, psychological support, physical medicine, and interventional procedures as needed (Kaye et al., 2010). As noted, the use of pain medications involves decision making based on multiple considerations. Ideally, the treatment plan is a mutual process among health care providers, patients, and caregivers, with the goal of optimizing quality of life and functioning (Wells et al., 2008). An effective pain management strategy includes a careful discussion of risks versus benefits, and frequent reviews of drug regimens used by older adults. Guidelines from the AGS recommend the establishment of realistic goals with the acknowledgment that complete resolution of pain may not be achievable (Fine, 2012). Pain management is often a process of trial and error that aims to balance medication effectiveness with management of side effects, often in conjunction with the other treatment modalities mentioned.

Guiding principles for optimal pain management in older adults include the following components (Buffum et al., 2007; Gordon et al., 2005). First, the treatment of pain should be initiated immediately on the detection of pain. Second, regularly scheduled (rather than “as needed”) dosing of pain medications should be employed. Additionally, multiple modalities for the evaluation of pain control should be used, including verbal, behavioral, and functional responses to pain medication, selected based on the patient’s ability to communicate and interact. Pain medication should be titrated according to these responses, and a pain medication regimen should be chosen based on what is known about each individual patient. This includes the interaction of pain medications with other medications, and the knowledge of pain medication side effects, such as constipation. Titration must also take into account the severity of cognitive impairment and how this affects the patient’s ability to express and report pain. For individuals with cancer-related pain, the WHO provides a three-step analgesic ladder that has been widely used as a guide for treating pain in this population. Choices are made from three drug categories based on pain severity: the nonopioids, opioids, and adjuvant agents. Combinations of drugs are used because two or more drugs can treat different underlying pain mechanisms, different types of pain, and allow for smaller doses of each analgesic to be used, thus minimizing side effects. In 2008, the WHO established guidelines for the use of Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, and oxycodone) in older adults with cancer and noncancer pain (Pergolizzi et al., 2008). Their criteria for the selection of analgesics in older adults with cancer are based on the type of pain, efficacy of the medication, side-effect profile, potential for abuse, and interactions with other medications (Pergolizzi et al., 2008). These guidelines make clear that Step III opioids are the gold standard of treatment for cancer pain and are also efficacious in noncancer diseases. The authors point out, however, a dearth of specific studies investigating the use of these drugs in older adults.

Special Considerations for Administering Analgesics

When considering the addition of pain medication to an older, and potentially frail person’s medication regimen, several issues must be evaluated. Confounding factors for medication side effects include comorbidities, the use of multiple medications, and drug-to-drug interactions (Klotz, 2009). Advancing age is associated with physiological changes that can result in increased plasma levels of various medications (Fine, 2012). A reduction in renal and hepatic function, for example, can mean reduced efficacy in drug clearance and elimination. If not dosed accordingly, there is a higher risk for side effects and potential toxicity. These changes are the result of alterations in the pharmacodynamics (mechanisms of drug action in the body) and pharmacokinetics (processes of drug absorption, distribution, metabolism, and elimination in the body; Klotz, 2009) that occur with advancing age. It is important to take into account that adverse effects are not uncommon in older adults, regardless of whether a medication is new or used frequently (Makris et al., 2014). Adverse effects increase in the presence of comorbidities and the use of multiple medications. These effects are also a frequent cause for discontinuing pain medications. When starting a new medication, frequent follow-up is recommended to monitor for effect, side effects, and the need to titrate or change medications (Makris et al., 2014). Specific side effects to consider when prescribing and/or administering pain medications to the older adult include risks for sedation, mental status changes and cognition, balance, and gastrointestinal (GI) side effects—including bleeding and constipation (Buffum et al., 2007).

Recommendations for beginning pain medication treatment include starting at low doses and gradually titrating upward, while monitoring and managing side effects. The adage “start low and go slow” is often used. Titrate doses upward to desired effect using short-acting medications first, and consider using longer duration medications for long-lasting pain, once drug tolerability has been established. The use of short-acting medications can continue following the addition of long acting drugs in order to address breakthrough pain. If short-acting medications are being used regularly, then a reassessment of pain is essential to evaluate for the need to increase the long-acting medication (Fine, 2012). For most older adults, with mild to moderate pain, or those taking pain medications on an as-needed basis, choose a drug with a short half-life and the fewest side effects, if possible (Pasero & McCaffery, 2011; Wells et al., 2008).

The least invasive mode of drug delivery should be used. For most older adults, the oral route is the most convenient, provided their ability to swallow is intact. This route also provides steady plasma levels of medications. When a more rapid onset is needed, or when patients cannot take oral medications, intravenous, subcutaneous and intramuscular routes can be utilized. These modalities, however, tend to have a shorter duration, and require a skill set to administer; transdermal, rectal, and oral transmucosal routes can also be used (Fine, 2012). Intramuscular injections should generally be avoided in older adults because of the potential for tissue injury and unpredictable absorption, and because they produce pain. Overall, adopting a preventive approach to pain management, whenever possible, is recommended. By treating pain before it occurs, less medication is required than to relieve it (Wells et al., 2008). Examples of pain prevention are around-the-clock dosing and dosing before a painful treatment or event.

Types of Analgesic Medications

The AGS published updated guidelines for pain management in older adults in 2009 (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). Information on accessing these guidelines is included in the Resources section at the end of this chapter. The guidelines provide comprehensive information about managing persistent pain, but the recommendations apply to acute pain management as well. Thus, the reader is referred to these guidelines for more comprehensive information.

Nonopioid Medications. Acetaminophen is recommended as the drug of first choice for the treatment of persistent pain in older adults (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). It is considered the drug of choice for mild to moderate pain in older adults (Herr, Bjoro, Steffensmeier, et al., 2006). It is recommended that the total daily dose should not exceed 4 g/d (maximum 3 g/d in frail elders). A 50% to 75% reduction in the daily maximum dose should be made for older adults with hepatic insufficiency or a history of alcohol abuse (Food and Drug Administration [FDA] Announcement, 2011).

Nonsteroidal anti-inflammatory drugs (NSAIDs) are more effective than acetaminophen for patients with inflammatory pain, such as the pain associated with rheumatological diseases. Particular caution must be used when prescribing NSAIDs, to older adults, especially those with low creatinine clearance, gastropathy, cardiovascular disease or diseases that deplete vascular volume, such as congestive heart failure. In older adults, NSAID-induced side effects increase in frequency with advancing age. These side effects can include GI discomfort and bleeding. There are two types of NSAIDs: nonselective (e.g., ibuprofen, naproxen) and cyclooxygenase (COX)-2 selective inhibitors. The COX-2 drugs were introduced in the hopes of reducing the GI side effects seen with the nonselective NSAIDs. However, the GI protection provided by the COX-2 drugs is incomplete, and the side effects of both types of NSAIDs are otherwise unchanged. Two of the initial COX-2 drugs were withdrawn from the market because of their association with an increased risk for adverse cardiovascular events. All NSAIDs, including nonselective and COX-2 drugs, should be used with caution in older adults, especially in those with underlying cardiovascular diseases, renal disease, and history of gastropathy. The concomitant use of gastro-protective agents, can reduce the risk of GI adverse events (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009).

Opioid Medications. Opioid drugs (e.g., codeine and morphine) are effective at treating moderate to severe pain from multiple causes. According to the AGS (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009), opioid analgesics can be used safely and effectively in older adults if they are properly selected and monitored. Patients with persistent uncontrolled pain requiring opioid therapy should receive around-the-clock, scheduled dosing, to ensure steady-state levels. As noted, the use of extended-release opioids can reduce the need for frequent dosing and provide better relief (Kaye et al., 2010). All providers caring for older patients should prescribe opioids based on clearly defined therapeutic goals. Prescribing should occur based on serial attempts to reach these goals, with the lowest doses chosen based on efficacy and side effects.

Many older adults and health care providers are reluctant to use opioids because of fears of addiction, side effects, and intolerance. Potential side effects include nausea, pruritus, constipation, drowsiness, cognitive effects, and respiratory depression. The most serious side effect, respiratory depression, is rare and can be mitigated by slow dose escalation and careful monitoring for signs of sedation (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Wells et al., 2008). To prevent constipation, preventive measures should be initiated when the opioid is started (e.g., stool softeners, adequate fluid intake, moderate activity; AGS Panel on Persistent Pain in Older Persons, 2002).

Adjuvant Drugs. Adjuvant drugs are those drugs administered in conjunction with analgesics to relieve pain. There are numerous drugs from various classes that provide pain relief beyond their intended indications. These primarily include antidepressants and antiepileptic medications. These adjuvant medications are often administered with nonopioids and opioids to achieve optimal pain control through additive analgesic effects, or to enhance response to analgesics. It is strongly recommended that patients with neuropathic pain be considered for adjuvant therapy (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Fine, 2012). Although tricyclic antidepressants (e.g., nortriptyline, desipramine) have shown dual effects on both pain and depression, they should be avoided because of their anticholinergic effects, which in the elderly increase the risk of side effects, including confusion, dry mouth and constipation among other risks associated with toxicity (Campanelli, 2012). Antidepressants that exert serotonin reuptake inhibition and mixed serotonin and norepinephrine uptake inhibition are safer to use in older adults as aduvant therapy for pain management because they are effective in the treatment of neuropathic pain and have a better side-effect profile (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). Anticonvulsants (e.g., gabapentin) may be used as adjuvant drugs for neuropathic pain, such as trigeminal neuralgia and postherpetic neuralgia, and they have fewer side effects than tricyclic antidepressants (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). They must, however, be titrated slowly and diligent monitoring is necessary to avoid side effects such as lethargy and confusion. Local anesthetics, such as lidocaine as a patch, gel, or cream, can be used as an additional treatment for the pain of postherpetic neuralgia.

Equianalgesia refers to equivalent analgesia effects. Understanding equianalgesic dosing (e.g., dose conversion chart, conversion ratio) improves prescribing practices for managing pain in older adults. Equianalgesic dosing charts provide lists of drugs and doses of commonly prescribed pain medications that are approximately equal in providing pain relief and can provide practical information for selecting appropriate starting doses when changing from one drug to another or finding optimal drug combinations (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Pasero & McCaffery, 2011; Pasero, Portenoy, & McCaffery, 1999).

Drugs to Avoid in Older Adults

Some medications should be generally avoided in older adults because they are either ineffective for them or cause higher risk of side effects. Per the updated Beers Criteria (2012), non-cox-selective NSAIDs—especially indomethacin, which has the most adverse effects of all of the NSAIDS—should be avoided. Additionally, certain opioids, such asmeperidine (Demerol) and pentazocine (Talwin), are considered to be inappropriate analgesic medications for older adults. Skeletal muscle relaxants should also be avoided because of adverse effects. These medications, like opioids, can cause central nervous system side effects, including confusion or hallucinations, and can increase the risk of falls. Because of the need to treat symptoms associated with pain syndromes, and often medication side effects, considerations to medication selection will be an imperative part of the treatment plan. When treating side effects using medications, such as sedatives, antihistamines, and antiemetics, consideration must be given to their long duration of action and side-effect profiles. These classes of drugs can increase risk of falls, hypotension, anticholinergic effects, and sedating effects (Gordon et al., 2005).

Nonpharmacological Pain Treatment

Older adults frequently experience multimorbidity with high prevalence of pain related to muscular skeletal conditions and depressive symptoms (Patel et al., 2013). Consequently, polypharmacy is common among older adults to relieve pain and other symptoms. And, therefore, special consideration should be paid to relieve multiple symptoms that they experience without adding further pharmacological regimen, if possible. Thus, nondrug strategies are a crucial component of pain management, which may be used alone or in combination with pharmacological therapies. The most commonly reported nonpharmacological strategies were exercise, nutritional supplements, ointments, massage, relaxation (e.g., breathing, meditation, imagery, music), activity modification, massage, and heat or cold application, although use of transcutaneous electrical nerve stimulation (TENS), chiropractics, vitamins, herbal remedies, magnets, and acupuncture was less prevalent in older adults (Stewart et al., 2012; Wells et al., 2008). Recently published pain management guidelines included the nonpharmacological therapies as recommendations (Abdulla et al., 2013; Zhang et al., 2008). Some of the recommended nonpharmacological therapies are acupuncture, mindfulness meditation, massage, TENS, and cognitive behavioral therapy (CBT), and supplements such as glucosamine and topical capsaicin cream (Abdulla et al., 2013; Zhang et al., 2008). Some of these nonpharmacological therapies demonstrated high levels of evidence (Makris et al., 2014). Older adult patients should be encouraged to use multimodal approaches, including nonpharmacological treatment, for more effective pain management (Makris et al., 2014).

Types of Nonpharmacological Treatment Strategies

Pain is strongly associated with biopsychosocial determinants such as anxiety and depression (Abdulla et al., 2013; Denise et al., 2014). Thus, multimodal approaches, including psychosocial interventions in combination with the pharmacological therapies for pain relief, are being increasingly encouraged (Abdulla et al., 2013; Keefe, Porter, Somers, Shelby, & Wren, 2013; Makris et al., 2014). Nonpharmacological pain treatment strategies, such as acupuncture, massage, mindfulness meditation, and yoga, may be beneficial to manage pain both physically and psychologically. Physical pain relief modalities include, but are not limited to, TENS, use of heat and cold, massage, physical activity, acupuncture, and exercise. Psychological pain relief modalities include guided imagery, mindfulness meditation, CBT, biofeedback, tai chi, and yoga (Abdulla et al., 2013; Makris et al., 2014). However, many physical and psychological nonpharmacological pain relief modalities are not often mutually exclusive and are rather beneficial for both aspects of pain treatment. Various types of dietary supplements are also commonly used nonpharmacological pain treatments among older adults. To date, many of these nonpharmacological strategies have been empirically evaluated for their effectiveness in pain management for older adults and reviewed for the level of evidence ratings (Makris et al., 2014). A brief explanation of some nonpharmacological pain treatments follows.

Acupuncture. Acupuncture is recommended mostly as an adjuctive therapy and considered an effective treatment with safety according to the reports of meta-analysis (Vickers et al., 2012), evidence-based review and guidelines (Abdulla et al., 2013; Makris et al., 2014; Park & Hughes, 2012), Osteoarthritis Research Society International (OARSI; Zhang et al., 2008) and AGS (2002), whereas a recent randomized clinical trial conducted in Australia (Hinman et al., 2014) does not support acupuncture as an effective treatment for chronic knee pain. Acupuncture demonstrates consistent evidence of effectiveness to manage various types of chronic pain, including back pain, shoulder pain, neck pain, and knee pain (Park & Hughes, 2012). Among the clinical trials, however, the frequency and duration of an acupuncture treatment varied from three times per week for 2 weeks to one time a week for 26 weeks.

Massage. Massage is considered to be an effective adjunctive therapy without serious adverse events (Abdulla et al., 2013; AGS, 2002; Makris et al., 2014; Zhang et al., 2008). Massage shows conflict findings and, based on the type of pain location, is more or less effective in managing chronic nonmalignant pain (Tsao, 2007). To be beneficial for pain, frequencies or duration of massage modalities have not been established in the studies.

Mindfulness Meditation. Meditation shows overall limited benefit to manage pain (Abdulla et al., 2013). One small clinical trial reported that 8 weeks of a meditation program was as effective as the education program to improve chronic low back pain (Morone, Rollman, Moore, Qin, & Weiner, 2009). Massage therapy may be effective in managing chronic low back pain and can be more beneficial when it is combined with education and exercise (Furlan, Imamura, Dryden, & Irvin, 2009).

TENS. TENS appears to be helful in managing pain particularly when it is combined with acupuncture (Abdulla et al., 2013; Park & Hughes, 2012). To obtain pain relief with TENS, adequate intensity and dosing should be established and applied (DeSantana, Walsh, Vance, Rakel, & Sluka, 2008).

Tai chi. Tai chi is a movement-based exercise regimen (Makris et al., 2014) that may be effective in managing pain and improving physical functioning without serious adverse events according to the findings of systematic review and meta-analysis (Kang, Lee, Posadzki, & Ernst, 2011); however, it may be considered as an option to manage pain if this movement-based approach can be delivered appropriately for an individual older adult (Abdulla et al., 2013). Despite many trials of tai chi, the effectiveness of this intervention for chronic pain in older adults is still inconclusive because of methodological issues in the studies (Hall, Maher, Latimer, & Ferreira, 2009) and, therefore, receives only limited support. Recommendations should be individualized based on the person’s comorbidities, adherence, personal preference, and feasibility of exercise.

CBT. Cognitive behavioral treatments have also shown significant improvement in pain and mobility caused by osteoarthritis among older adults (Baird, Murawski, & Wu, 2010) and is recommended for pain relief if it is delivered by a professional therapist (Abdulla et al., 2013; AGS, 2002). One study (Green, Hadjistavropoulos, Hadjistavropoulos, Martin, & Sharpe, 2009) indicated that CBT intervention once a week for 10 weeks of provided maladapative pain behavior and higher level of relaxation, which is indicative of better coping.

Although these therapies are not an exhaustive list of nonpharmacological regimens, they demonstrate the levels of evidence to be used in older adults. Each of these nonpharmacological modalities has demonstrated mixed results, largely because of individual patient preferences and methodological differences in how the studies were conducted. Thus, there is no conclusive evidence that these modalities relieve pain. Among them, acupuncture seems to have the most consistently effective results for pain management. These nonpharmacolofical modalities should be considered on an individualized basis, depending on patient preference and response, physical function, psychological functioning, acceptability, and as an adjunct to pharmacological treatment.

In summary, nonpharmacological treatments are widely used comfort measures to help manage pain. These approaches are challenging to study because it is difficult to (a) find a convincing placebo and (b) establish optimal dose, frequency, and duration of an intervention. In addition, studies have contributed inconsistent findings because of differences in study designs, inconsistent measures, and mixed intervention durations. It may be also true that a specific type of nonpharmacolofical modality works for the specific type of chronic pain, which has not been fully investigated. Despite the lack of strong evidence and rigorous support for these nondrug approaches, they have received growing interest among the community of science and recently made a great advance. Thus, nurses and health care providers should consider all possible combinations and options for managing pain, and discuss these approaches with their older adult patients to identify the best options that are appropriate for each individual patient.

Special Considerations of Using Nonpharmacological Treatment for Older Adults

Individuals vary widely in their preferences for and ability to use nonpharmacological interventions to manage pain. Spiritual and/or religious coping strategies, for instance, must be consistent with individual values and beliefs. Other strategies, such as guided imagery, biofeedback, or relaxation, may not be feasible for cognitively impaired older adults. Tai chi or exercise should be customized based on functional ability and mental status of an individual adults. Therefore, it is important for health care providers to consider a broad array of nonpharmacological pain management strategies and to tailor selections to the individual. It is also important to gain individual and family input about the use of home and folk remedies because use of herbals or home remedies is often not disclosed to health care providers and may result in negative drug–herb interactions (Yoon & Horne, 2001; Yoon, Horne, & Adams, 2004; Yoon & Schaffer, 2006).

IMPROVING PAIN MANAGEMENT IN CARE SETTINGS

Nurses have a critical role in assessing and managing pain. The promotion of comfort and relief of pain is fundamental to nursing practice and, as integral members of interdisciplinary health care teams, nurses must work collaboratively to effectively assess and treat pain. Given the prevalence of pain in older adults and the burgeoning aging population seeking care in our health care systems, this nursing role is vitally important. In addition, nurses have the primary responsibility to teach the patient and family about pain and how to manage it, both pharmacologically and nonpharmacologically. As such, nurses must be knowledgeable about pain management in general, and about managing pain in older adults in particular. Moreover, nurses are responsible for basing their practice on the best evidence available, and helping to bridge the gap among evidence, recommendations, and clinical practice.

Nurses, however, must work within an organizational climate that supports and encourages efforts to improve pain management. These efforts must go beyond simply distributing guidelines and recommendations because this approach has not been effective (Dirks, 2010). Some quality-improvement processes that should be considered in promoting improved pain management include the following (Dirks, 2010):

Stay updated, free articles. Join our Telegram channel

Join