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Pain Management and the Elderly

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The elderly pain population presents many challenges for pain practitioners, including comorbid medical conditions, polypharmacy, and declining physical and mental function. Learn more about how to manage this challenging age group.

Authors: Robert J. Gatchel, PhD, ABPP et al

Pain and pain management are a growing concern among Americans age 65 and older.1 A recent analysis of data from a National Institutes of Health (NIH)-funded study found that more than half (53%) of the older adults surveyed reported having bothersome pain in the last month; three-quarters of them reported having pain in more than 1 location. Bothersome pain, particularly in multiple locations, also was associated with decreased physical capacity.2

The November issue of Practical Pain Management highlighted the positive benefits of incorporating an exercise program, even light exercise, into a pain management program for elderly patients.3,4The benefits include improving physical function, reducing isolation and depression, and enhancing balance and mental acuity.

In this article, the authors present a variety of treatment options, ranging from medications, comorbid mental health issues, and comprehensive interdisciplinary pain management.

Medication Use in the Elderly

Treating pain in the elderly is complicated further by the fact that 75% of people age 65 and older have 2 or more chronic conditions—such as heart disease, diabetes, chronic lung disease, or arthritis.2 Despite the high prevalence of pain in the elderly, pain usually is undertreated. In 1 study, Maxwell et al found that pain is undertreated in about 21% of older adults in nursing homes.5 It should be noted that the undertreatment of pain in older adults is an especially significant problem for those who have severe dementia (Alzheimer’s disease).6 This is because they often have difficulty communicating their experience of pain due to major cognitive and linguistic impairments.

Each patient should be evaluated individually to identify the most effective strategies to use in hopes of achieving the best possible outcome with the least amount of side effects. This can be particularly problematic when working with the elderly population because they tend to face a unique set of challenges.7Patients may face physical limitations that make traditional recommendations, such as exercise, stretching, or balance tasks, extremely difficult or unfeasible. In addition, Macfarlane et al found that elderly populations were more likely to be prescribed medications as their course of treatment rather than physical therapy, alternative treatments, or specialist referrals.7 In fact, an elderly person, on average, takes approximately 9 or more medications per day,5 increasing his or her risk of adverse reactions from drug-to-drug interactions.8 In 2008, elderly people over the age of 65 represented more than 31% of individuals who were hospitalized due to an adverse drug reaction.9

Elderly patients also are at a higher risk of adverse drug events (ADEs) due to natural physiological changes in the body that come with age, such as the slowing of the gastrointestinal tract that may inhibit the absorption rate of some drugs, or the dwindling liver oxidation rate that can lengthen drug half-life.10

Some commonly prescribed drugs in the elderly include nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvant drugs such as antidepressants, and opioids.10

Medication Risks And Contraindications In the Elderly

NSAIDs

NSAIDs are used commonly to treat musculoskeletal pain in the elderly, with some prescribers favoring NSAIDs over opioids for pain management.11 NSAID use is frequent among the elderly, but these agents pose considerable risks to this population. Although NSAIDs may be beneficial in some patients without heart or renal issues, they may interfere with certain necessary medications for blood disorders, heart problems, renal problems, or may be contraindicated with certain medications.12

Elderly patients are at increased risk for gastrointestinal toxicity associated with NSAIDs, specifically peptic ulcers.13 Gastro-protective drugs, such as misoprostol and proton pump inhibitors, could help those taking NSAIDs for long-term pain relief therapy,14 but only 40% of patients prescribed NSAIDs also are prescribed a gastro-protective medication.15

NSAIDs also are a common culprit in hospitalization due to drug-to-drug interactions because they interact negatively with commonly prescribed medications such as aspirin, selective serotonin receptor inhibitors (SSRIs), and antihypertensives.16An elderly person who suffers from an ADE that requires hospitalization has a mortality rate of 9%.17 Prescribers should be attentive to the past medical history of each patient, regardless of age, to avoid potential adverse drug reactions  (ADR) or drug-to-drug interactions.

Adjuvant Analgesics

Another common type of medication used in the elderly is adjuvant analgesics. These are medications whose primary focus is not to treat pain, but whose side effects have been found to assist in pain management, specifically in the management of neuropathic pain.18 Antidepressants are the most commonly prescribed form of adjuvant medication, and, overall, physicians prefer SSRIs over tricyclic antidepressants (TCAs). Elderly patients, however, are 73% more likely to be prescribed TCAs than SSRIs.19

The high number of TCAs prescribed to elderly patients exposes them to an increased risk of ADRs, including loss of equilibrium, which can contribute to an increase of falls and injuries; sudden decreases in blood pressure; sleep disturbances; and arrhythmias.20 A study by Ray et al found that although a low dose (<100 mg) of TCAs did not increase the risk of cardiac death, a high dose (>100 mg) was associated with a greater number of cardiac deaths.21

Opioids

The World Health Organization 3-Step Analgesic Ladder for pain management recommends that opioids be used in Step 2 and 3, after the use of NSAIDs or adjuvant medications (Step 1) have failed to provide pain relief.22 Opioids, such as morphine, oxycodone, fentanyl, and methadone, commonly are prescribed to treat both acute and chronic pain in adults. However, opioid medications have an addictive nature and are among the most abused substances in the United States.23

In a study of 10,372 nursing home residents reported to have persistent pain, 38.4% were on an opioid-based treatment plan.12As with other analgesics, the risks versus benefits associated with opioid-based treatment should be discussed prior to prescribing, especially in this vulnerable population.

Some of the risks the elderly may experience when taking opioids are constipation, nausea, gastrointestinal complications, respiratory depression, increased falls, and sleep disturbances.7Many of these ADRs are treated pharmacologically, which further increases the number of drugs the patient consumes each day.

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