RSD Support From Ones Who Care

Important Announcement

The MSN Groups service will close in February 2009. You can move your group to Multiply, MSN’s partner for online groups. Learn More

Topics in Advanced Practice Nursing eJournal. 2007;7(1)
©2007 Medscape

Assessment and Management of Pain in Older Adults: A Review of the Basics

Patricia Bruckenthal, PhD, RN, ANP;
Yvonne M. D'Arcy, MS, CRNP, CNS

Posted 05/24/2007

Abstract

Pain in patients older than 65 years of age is significantly undertreated and misunderstood. This may be based on the assumption that older patients either cannot tolerate stronger pain medications or do not experience pain in the same way as younger patients. However, many older patients have chronic conditions, such as arthritis or diabetic neuropathy, in which pain is a daily occurrence and affects quality of life. One of the biggest barriers to pain management in older patients is how to assess pain effectively. Most older patients can use a 0-10 pain scale, but other patients who are cognitively impaired are more complex to assess and require different types of pain assessment tools and techniques. More importantly, once the assessment is complete, trying to decide which pain medication is best for an older patient with organ impairment or complications of the aging process presents another set of issues. The discussion in the following article focuses on pain assessment and pain management options for the older patient.

Case Scenario: Arthritis Pain That Is "Acting Up"

Jane Jones is your neighbor. She is 72 years old and lives alone. She is quite active and likes to spend time outside. You often see her working in her garden when the weather allows or walking her dog. You haven't seen her recently, and you meet her one day as she comes out of her house. She tells you that her "arthritis is really acting up and her knees ache all the time." She has been trying to walk daily to maintain her activity.

She has diabetes and hypertension that are controlled with oral medications. Her feet have started to burn and the pain keeps her up at night. When you ask her what her doctor has said about her pain, she states, "Well, he thinks it is just a part of getting old and tells me to take acetaminophen when my knees or feet hurt. He tells me to do what I can and continue to try to stay active. He doesn't want to give me stronger pain medications because of my age. The pain is so bad, though, that I can't get out too much. When I go into his office, they ask me about my pain and I tell them it's a 6 on their pain scale. Don't you think there is something better that I can take for the pain? I'd give anything to get a decent night's sleep."

Jane Jones' dilemma is not unusual. She is an older patient with chronic daily pain. Her pain is not only musculoskeletal from her osteoarthritis, but she also has diabetic neuropathy in her feet. According to the American Geriatric Society, Jane would be a good candidate for careful use of opioids, possibly an extended-release medication, and the careful addition of an adjuvant medication for her neuropathy.

Jane's pain has certainly had an impact on her quality of life. She had a very good baseline activity level, and if her pain was relieved she might return to her former activity level. Given good pain control, Jane could return to the things that she loved doing. Without good pain control, Jane is limited to a life of limited activity and pain. The information in the following pages provides some options for better pain relief that would drastically improve Jane's quality of life.

About 80% of patients who live in long-term care facilities have chronic pain.^[1] Older patients who live in the community experience pain to a lesser degree, but it is still a significant number, reported to be as high as 25% to 50%.^[1] For minority patients who live in communities, the number of patients who reported experiencing daily pain was 28%, and physical limitations related to pain were reported to be 17%.^[2] Significant predictors for severe pain in ethnically diverse populations were:

Being a Medicaid recipient;

Having 2 or more comorbidities;

Having a low educational level; and

Psychological distress.

Generally, patients who have pain seek effective pain medication. However, 1 in 5 older patients reported taking pain medication only occasionally during a 1-week period of time. Is this imbalance a result of:

Undertreatment by prescribers;

Financial difficulties (ie, affording the cost of medications); or

Reluctance of older patients to take pain medications?

Consider the effects of untreated pain. Whatever the reason, the consequences result in^[1]:

Depression;

Anxiety;

Decreased socialization;

Sleep disturbances;

Impaired ambulation; and

Increased healthcare utilization and costs.

Older patients can remain active and productive if their pain is adequately relieved. Nurses caring for older patients can help advocate for better pain relief when they encounter patients who are not receiving appropriate treatment for pain. A healthcare provider can effectively treat pain in older patients, such as the patient in the case study, by careful prescribing, frequent reevaluation, and combining treatments to achieve better pain control.

...continued in reply

Clinical Assessment of Pain

The goals of a clinical assessment for pain in older adults are the same as those established for younger patients. Older individuals may be reluctant to report pain for several reasons:

Many older people think that pain is a normal part of aging;

They do not want to be a nuisance; and

They fear the consequences of acknowledging pain, such as expensive testing or hospitalization.

Nurses must be aware of the potential for underreporting pain and make every effort to pursue an evaluation of pain in this population. A comprehensive assessment includes:

Detailed history, including characterization of the present pain complaint, pain-related history, and the impact of the pain on the patient's quality of life;

Physical exam; and

Appropriate diagnostic assessment.

Medical History

The initial history should include detailed questioning about all known medical conditions and physical limitations. There are several possible sources for persistent pain related to a host of pathologic conditions, including:

Peripheral vascular disease;

Diabetes;

Poststroke syndrome;

Decubitus ulcers;

Oral/dental problems;

Contractures;

Degenerative joint disease;

Rheumatoid arthritis;

Previous fractures; and

Osteoporosis.

A history of liver, gastrointestinal, and kidney dysfunction is important to elicit because these may have an impact on pharmacologic treatment options. A complete medication history, including prescribed, over-the-counter, and herbal remedies, and alcohol consumption are necessary and will be considered in analgesic choices.

Present Pain Complaint

To evaluate the present pain complaint, characterize an individual's pain by:

Type;

Quality;

Location;

Intensity; and

Etiology.

Included is an evaluation of what factors make the pain better, worse, and what treatments have been used as well as the patient's response to treatments.

The type of pain that the patient describes may be caused by actual or potentially damaging stimuli to tissue (skin, muscle, bone, organs), or nociceptive pain. If it is caused by a primary lesion or dysfunction in the nervous system, it is referred to as neuropathic pain. Some patients may have both types, or pain of mixed etiology.

Individual self-report remains the most reliable indicator of pain, even for patients with mild cognitive impairment. For all older adults, the language used for assessment may need to be modified to include pain descriptors used by the patient, such as a pinching or squeezing type of pain or what the term "discomfort" means to the patient.

Pain is often thought of as being "high" on a continuum of discomfort, and a patient may respond that he or she does not have "pain" when questioned. However, patients may respond to words, such as achy, sore, or discomfort. Once a term to describe an individual's pain has been identified, it is recommended that this term be used throughout the assessment and reassessment of that individual's pain.

...continued in reply

Assessment Tools

Several assessment tools are available to evaluate the intensity and location of the pain complaint. Older adults can use typical 1-dimensional scales, such as^[3]:

The Numeric Rating Scale;

Verbal Rating Scale;

Visual Analog Scale; and

FACES Pain Rating Scale.

The Numeric Pain Rating Scale, the most commonly used pain rating scale, is a line with 0 (no pain) at one end and 10 (worst pain possible) at the opposite end. The patient is asked to rate pain intensity by picking the number that most closely represents the level of pain that the patient is experiencing.

The Verbal Rating Scale uses verbal descriptors -- such as mild, moderate, and severe -- or quality descriptors -- such as ache, agonizing, or discomfort -- to describe the pain. The FACES Pain Rating Scale uses a series of faces that range from happy to sad with tears. The patient is asked to pick the face that best represents the pain that he or she is experiencing.

For patients who have acute pain in which pain intensity is the key for assessment, or for trying to determine the efficacy of pain management intervention, the simple 1-dimensional scales work best. Older patients, especially those with mild cognitive impairment, may need extra time to respond and require larger print versions. It may be helpful to have a few different versions of 1-dimensional scales available, because the preference or ease of use of a scale may differ among older persons.^[4]

Multidimensional scales, such as the Brief Pain Inventory, are helpful because they include a body map so that the patient can mark the area that hurts as well as elicit information in regard to the impact of pain on functioning.^[5] The Brief Pain Impact Questionnaire is a practical tool for clinicians especially in assessment of older adults.^[5,6] When patients have chronic pain, the use of a multidimensional scale is indicated.

Assessment in the Cognitively Impaired

When assessing pain in severely cognitively impaired patients, the clinician must rely on behavioral indicators. These include^[7,8]:

Nonverbal cues, such as restlessness and guarding;

Verbal cues, such as crying, moaning, and groaning; and

Facial expressions, such as grimacing.

Changes in usual activity may also be an expression of pain.

There is tremendous variability in pain behavior, and often certified nursing assistants will be the first to notice behavioral changes, including^[9,10]:

Combativeness;

Resisting care;

Decreased social interactions;

Increased wandering;

Difficulty sleeping; and

Refusing to eat.

Several pain assessment tools have been developed for cognitively impaired long-term care residents.^[11,12] Assessment tools vary greatly in their reliability, validity, and applicability for easy clinical use. The Pain Assessment in Advanced Dementia (PAINAD) scale has been designed for use in patients with Alzheimer's disease. It is clinically very popular, but as with all tools in this category, the reliability and validity of the tools are an evolving process. The reader is encouraged to review these prior to adoption in clinical practice to see whether the tool is appropriate to the work setting.

A comprehensive assessment will enable the clinician to establish an appropriate plan of care. Some interventions will result in rapid improvement in pain, whereas others will require an interdisciplinary approach and a greater length of time for resolution. Reassessment at frequent intervals will serve as a guide as to whether chosen interventions are successful.

Pain Management for Older Adults

Pain management techniques should include both pharmacologic and nonpharmacologic approaches. Common goals are pain reduction and improved function.

...continued in reply

Nonpharmacologic Techniques

Some simple comfort measures can help reduce pain. Listening to music, watching television, and storytelling are all distraction techniques that allow patients to reduce their focus on pain. Massage, soft touch, and warm applications are relaxation techniques that are beneficial for patients who are open to these practices. Sensory stimulation in the form of pet therapy or folding warm clothes as well as cognitive therapies that include reading or reminiscing have all been used to reduce pain.^[13]

Participation in regular physical activity not only reduces pain, but enhances functional capacity and mood. Therefore, a physical activity program should be considered for all patients. The program should be individualized to meet the needs and preferences of the patient.^[14,15] This is especially important for older adults.

There is a wide range of nonpharmacologic interventions that may be helpful to older adults. The choice of intervention should be individually tailored on the basis of preference, ability to participate, and efficacy. Nonpharmacologic interventions may be effective alone or in combination with pharmacologic therapies.

Pharmacologic Pain Management Techniques

Pharmacologic management is the most common treatment for pain control in older adults. There are a variety of pharmacologic agents to treat pain in the elderly, and no 2 patients will respond in the same way. It is important that nurses be aware of specific properties of drugs that are prescribed and common age-related changes that can influence how drugs are metabolized and absorbed.

Starting with a low dose and titrating upward until pain relief is achieved must be balanced with the development of intolerable side effects or toxic serum levels. Using the least invasive route of administration and reassessing the effect of the drug are important components of effective analgesic management.

Older persons are more susceptible to adverse drug reactions for several reasons:

Physiologic changes resulting from aging vary among elders.

Body fat composition -- that is, muscle-to-fat ratio -- changes as people age.

Protein binding affects drug effectiveness. Decreased protein stores due to poor nutrition, for example, will affect the protein-binding capacity of certain medications.

Similarly, given that many older adults are on multiple medications, the drugs may compete for protein-binding sites, rendering 1 or more medications ineffective.

Functions that affect the absorption, metabolism, and clearance of drugs, including slowed gastrointestinal motility as well as decreased cardiac output and glomerular filtration rate.

Changes in sensory and cognitive perception, such as sedation or confusion, may be a risk for some patients due to potential side effects of both opioid and nonopioid medications, such as antidepressants and anticonvulsants.

Acetaminophen is generally considered the first line of treatment for elders with mild-to-moderate pain, especially of musculoskeletal origin. It must be used with caution in patients with:

Liver disease;

End-stage renal disease; or

History of alcohol abuse.

In patients with renal or liver disease a reduction of the maximum daily dose of 4 g of acetaminophen by 50% to 75% has been recommended.^[1]

If ineffective, progression to nonsteroidal anti-inflammatory agents is suggested. These types of agents are helpful only for short-term therapy. Gastrointestinal toxicity, platelet dysfunction, renal dysfunction, and sodium retention limit their usefulness in some patients.

Opioid analgesic drugs may help relieve moderate-to-severe pain. Although previously shown to be effective in treating patients with cancer pain, they are emerging as acceptable to use in patients with noncancer pain as well. One of the benefits of these medications is that they have no ceiling effect. In other words, escalating doses will not cause organ damage.^[16] They are limited, however, by side effects, such as:

Nausea;

Vomiting;

Itching;

Sedation; and

Constipation.

Usually, the patient will become tolerant to most of these side effects. If not, it is sometimes helpful to switch to another opioid medication or add an antiemetic. It is important to monitor older people for safety due to dizziness or potential for dehydration due to nausea and vomiting. All individuals on opioids should have a bowel regimen initiated to maintain regularity.

Adjuvant medications are those medications not formally classified as analgesics, but have pain-relieving properties. They have been shown to be most helpful for treating neuropathic pain. Topical agents, such as lidocaine 5% patch (Lidoderm) and capsaicin, have been helpful in relieving pain associated with postherpetic neuralgia and diabetic neuropathy.

Specific antidepressants and anticonvulsants have been helpful in treating various nerve-related pain as well. Side effects, such as dizziness and dry mouth, should be monitored.^[16]

Diagnosis;

Preference; and

Tolerance of the intervention.

AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50:S205-S224. Abstract

Reyes-Gibby CC, Aday LA, Todd KH, Cleeland CS, Anderson KO. Pain in aging community-dwelling adults in the United States: non-Hispanic whites, non-Hispanic blacks, and Hispanics. J Pain. 2007;8:75-84. Abstract

Brunton S. Approach to assessment and diagnosis of chronic pain. J Fam Pract. 2004;53(suppl):S3-S10.

Herr K, Mobily P. Comparison of selected pain assessment tools for use with the elderly. Appl Nurs Res. 1993;6:39.

Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore. 1994;23:129-138. Abstract

Weiner D, Herr K, Rudy T. Persistant Pain in Older Adults: An Interdisciplinary Guide for Treatment. New York: Springer Publishing Company; 2002.

Feldt KS. The checklist of nonverbal pain indicators (CNPI). Pain Manag Nurs. 2000;1:13-21. Abstract

Feldt KS, Ryden MB, Miles S. Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture. J Am Geriatr Soc. 1998;46:1079-1085. Abstract

Buffum MD, Miaskowski C, Sands L, Brod M. A pilot study of the relationship between discomfort and agitation in patients with dementia. Geriatr Nurs. 2001;22:80-85. Abstract

Cohen-Mansfield J, Creedon M. Nursing staff members' perceptions of pain indicators in persons with severe dementia. Clin J Pain. 2002;18:64-73. Abstract

Herr K, Bjoro K, Decker S. Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review. J Pain Symptom Manage. 2006;31:170-192. Abstract

van Herk R, van Dijk M, Baar FP, Tibboel D, de Wit R. Observation scales for pain assessment in older adults with cognitive impairments or communication difficulties. Nurs Res. 2007;56(1):34-43.

Kovach CR, Weissman DE, Griffie J, Matson S, Muchka S. Assessment and treatment of discomfort for people with late-stage dementia. J Pain Symptom Manage. 1999;18:412-419. Abstract

O'Grady M, Fletcher J, Ortiz S. Therapeutic and physical fitness exercise prescription for older adults with joint disease: an evidence-based approach. Rheum Dis Clin North Am. 2000;26:617-646. Abstract

Gloth MJ, Matesi AM. Physical therapy and exercise in pain management. Clin Geriatr Med. 2001;17:525-535, vii. Abstract

Argoff C, Cranmer K. The pharmacological management of chronic pain in long-term care settings: balancing efficacy and safety. Consultant Pharmacist. 2003;18(supplC):4-18.

Patricia Bruckenthal, PhD, RN, ANP, Clinical Associate Professor of Nursing and Adult Health, State University of New York at Stony Brook School of Nursing, Stony Brook, New York; Nurse Practitioner, Pain Management and Headache Treatment Center, North Shore/Long Island Jewish Health Systems, Manhasset, New York

Yvonne M. D'Arcy, MS, CRNP, CNS, Pain Management and Palliative Care Nurse Practitioner, Suburban Hospital, Bethesda, Maryland

Disclosure: Patricia Bruckenthal, PhD, RN, ANP, has disclosed that she has received grants for educational activities and has served as an advisor or consultant to Endo Pharmaceuticals.

Disclosure: Yvonne M. D'Arcy, MS, CRNP, CNS, has disclosed that she has served as an advisor or consultant to Endo, Pricara, and Pfizer. Ms. D'Arcy has also disclosed that she serves on the speaker's bureau for Endo.

Abstract

Clinical Assessment of Pain

Medical History

Present Pain Complaint

Assessment Tools

Pain Management for Older Adults

Nonpharmacologic Techniques

Pharmacologic Pain Management Techniques

The Bottom Line

References

Important Announcement The MSN Groups service will close in February 2009. You can move your group to Multiply, MSN’s partner for online groups. Learn More
RSD Support From Ones Who Care	[email protected]