How to manage pain effectively in the elderly

28 Oct 2014  |  Print

How to manage pain effectively in the elderly

The global population is aging rapidly. In 1975, the proportion of people who were aged over 60 was less than 10% globally; by 2025, it will be around 15%, and by 2050 around 20%.[1] In developed regions, 30% of people will be aged over 60 years by 2050.[1]

This raises important social questions. For example, how we can achieve healthy aging for this elderly population sector? Helping them to maintain an active, independent lifestyle will be crucial and, amongst other things, this will require appropriate management of pain.

Pain burden in the elderly

The elderly have a much higher burden of pain than younger people. Age is a significant predictor of chronic pain, with greatly increased rates of angina and arthritis-related pain,[2] as well as neuropathic pain.[3] Furthermore, pain is typically more intense in older people: moderate to severe pain is more common in the over-65s than in younger age groups.[4]

Pain has a huge impact on sufferers, irrespective of age. In addition to the obvious distress it causes, it is also linked with:

  • Disability: Five of the 11 most common causes of disability are pain-related, including musculoskeletal disorders and osteoarthritis (OA)[5];
  • Reduced functioning: In a study of patients with OA, impairments in sleeping, walking, shopping, dressing and bathing were each reported by >50% of participants[6];
  • Reduced quality of life (QoL): In a study of patients with chronic pain, all QoL domains on the SF-36 questionnaire – including physical and social function and general health – deteriorated as pain severity increased[7];
  • Mortality: Severe chronic pain is significantly associated with all-cause mortality, even after adjusting for sociodemographic factors and long-term illness.[8]

Interestingly, the presence of walking disability in patients with OA is also a significant predictor of increased mortality.[9] This highlights the continuum between painful disease, disability and mortality. Hence, treating pain in elderly patients not only reduces disability, it can also help them live longer.

Age adds complexity

As with many medical conditions, the evidence base for the treatment of pain in elderly patients is deficient, because older subjects are typically excluded from clinical trials.[10] This makes treatment selection challenging.

Furthermore, several factors make pain management particularly complex in elderly patients. The first is the difficulty of adequately assessing pain in many older people, particularly those suffering from cognitive impairments and other communication problems (eg, confusion or aphasia).

The second factor is inadequate access to healthcare services, for example owing to government spending limitations. This can lead to under-treatment.

The third factor is multi-morbidity, which is the norm among most elderly patients. Recent data suggested that the majority of over-65s have two or more long-term conditions, while the majority of over-75s have three or more such conditions.[11] Across all age groups, patients with painful conditions have a 36% chance of comorbid hypertension, a 31% chance of comorbid depression, a 13% chance of comorbid diabetes, and a 10% chance of comorbid chronic obstructive pulmonary disease.[11]

This has major implications for the management of pain in elderly patients. Most importantly, it makes pain harder to treat.

For example, non-steroidal anti-inflammatory drugs (NSAIDs) used in OA are contraindicated in patients with severe heart failure or hepatic impairment[12] – both of which are more common in older patients than their younger counterparts. Similarly, anticonvulsants used in the treatment of neuropathic pain are often associated with dizziness and somnolence.[13] This can increase the likelihood of falls in elderly patients,[13] particularly those with comorbid mobility problems.

The impact of multi-morbidity can also manifest in problematic drug-drug interactions. For example, selective serotonin reuptake inhibitors (used to treat depression) have increased potential to cause convulsions when used alongside the pain medication, tramadol.[14]

Pain management strategies in elderly patients

The additional complexities associated with older patients have important implications for therapeutic decision making. However, given the morbidity and mortality associated with a failure to treat pain,[5-9] it is essential that pain management is given appropriate priority.

This can be achieved with a few simple safeguards. When prescribing pain medications to elderly patients, bear in mind all associated precautions and potential side effects. Furthermore, unnecessary polypharmacy should be avoided. When polypharmacy is necessary, steps should be taken to minimize drug-drug interactions. These may include introducing new drugs one at a time, careful dose escalation, screening for drug interactions, and education of patients and their carers.

Can pain treatments be used effectively and safely in older people? Evidence suggests so. For example, in a recent study in patients aged ≥65 years, the use of NSAIDs reduced all-cause mortality and was not associated with increased risk of myocardial infarction.[15]

In conclusion, it is possible, and imperative, to effectively manage pain in the elderly. The tailored use of appropriate medications, along with regular follow up, will ensure adequate pain relief without unduly elevating the risk of side effects.

References:

1. United Nations Department of Economic and Social Affairs. World Population Ageing: 1950-2050. Available at: www.un.org/esa/population/publications/worldageing19502050/. Accessed 30 September 2014.

2. Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet 1999;354:1248-1252.

3. Boogaard S, De Vet HC, Faber CG, Zuurmond WW, Perez RS. An overview of predictors for persistent neuropathic pain. Expert Rev Neurother 2013;13:505-513.

4. The Societal Impact of Pain. The impact of pain: results of a survey in big 5 EU countries. Available at: www.sip-platform.eu/tl_files/redakteur-bereich/Symposia/Symposia%202011%20Programm/Plenary%203%20May/cesar_margarit.pdf. Accessed 30 September 2014.

5. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2163-2196.

6. Crichton B, Green M. GP and patient perspectives on treatment with non-steroidal anti-inflammatory drugs for the treatment of pain in osteoarthritis. Curr Med Res Opin 2002;18:92-96.

7.  Smith BH, Elliott AM, Chambers WA, et al. The impact of chronic pain in the community. Fam Pract 2001;18:292-299.

8. Torrance N, Elliott AM, Lee AJ, Smith BH. Severe chronic pain is associated with increased 10 year mortality. A cohort record linkage study. Eur J Pain 2010;14:380-386.
9. Nüesch E, Dieppe P, Reichenbach S, et al. All cause and disease specific mortality in patients with knee or hip osteoarthritis: population based cohort study. BMJ 2011;342:d1165.

10. Watts G. Why the exclusion of older people from clinical research must stop. BMJ 2012;344:e3445.

11. The Scottish School of Primary Care’s Multimorbidity Research Programme. Multimorbidity in Scotland. Available at: www.impressresp.com/index.php?option=com_docman&task=doc_view&gid=92&Itemid=70. Accessed 30 September 2014.

12. National Institute for Health and Care Excellence. NSAIDs – prescribing issues. Available at: http://cks.nice.org.uk/nsaids-prescribing-issues#!scenariorecommendation:1. Accessed 30 September 2014.

13. Lyrica, Summary of Product Characteristics. Available at: www.medicines.org.uk/emc/medicine/14651/SPC/Lyrica+Capsules/. Accessed 30 September 2014.

14. Tramadol hydrochloride, Summary of Product Characteristics. Available at: www.medicines.org.uk/emc/medicine/24186. Accessed 30 September 2014.

15. Mangoni AA, Woodman RJ, Gaganis P, Gilbert AL, Knights KM. Use of non-steroidal anti-inflammatory drugs and risk of incident myocardial infarction and heart failure, and all-cause mortality in the Australian veteran community. Br J Clin Pharmacol 2010;69:689-700.

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