Healthcare Communication

The Elderly Population

 Pain is common in older adults.  Approximately 85% of adults over 65 experience pain at least once a year and almost 60% have multiple pain complains (Wallace, 2001).  Because of cognitive impairment, the elderly adult may not ask for pain relief.  

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Pain assessment in the elderly may be complicated by cognitive decline, sensory-perceptual deficits, and age-related changes. The elderly have multiple medical problems and multiple complaints making adequate assessments of pain difficult and confusing for the practitioner. Even with appropriate assessment, this group of patients may, because of memory problems or confusion, present with special treatment issues. They might not understand directions for taking medications, might forget these directions, or just forget to take their medications altogether. 

It is estimated that 25% to 50% of community-dwelling older adults also experience pain that interferes with their ADL’s.  Elderly patients tend to be reluctant to report pain-related symptoms. This may be due to the belief that pain is a necessary part of older life, to fear of being negatively judged for having pain, or to the expectation that the clinician will give a low priority to pain, compared with other medical problems. Elderly patients may also fear that pain foreshadows death or serious illness. And because older adults may believe that pain is something that must be endured, creative methods may be developed to deal with it.  

Although many diseases that cause pain are common with aging, pain itself is not a normal part of aging.

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Long-term care facilities have a high percentage of patients with dementia and clinicians may have difficulty assessing pain in these patients.  Studies indicate that commonly used pain scales, such as the pain thermometer and other verbal descriptor scales, can be used successfully in many patients with dementia.  The key is to keep assessments simple with the use of visual aids and simple questions with yes or no answers. 

For the elderly population, change in body position, heat, exercise, distraction and rest may help alleviate pain.  Mental imaging, positive thinking, and prayer and other spiritual interventions are also effective.  

 

 

The use of pharmacologic agents for pain management must be closely monitored in the elderly population.  Compared with younger patients, elderly patients show many physiologic differences that result in higher, more prolonged plasma drug concentrations, which may cause more adverse effects, toxicity, and unfavorable drug interactions.   The most dramatic change in drug clearance is typically due to a decline in renal function. Many drugs are excreted renally, either as unchanged drug or as a metabolite that may retain some original function, however, the metabolite may also be toxic. Although renal function decline is typical, it is not universal, and some elderly retain fairly normal renal function.

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Special problems with medications that may present because changes in aging populations include:

  • Increased risk of stomach irritation, water retention, hypertension, headache, and kidney disorder with the taking of NSAIDs
  • Quicker onset of action and prolonged time of action of opioids.
  • Mental changes and confusion with opioids and local anesthetics
  • Urinary retention, severe constipation and even obstipation with opioids or antidepressants.
  • Severe dizziness, increased risk of falling with antidepressants, opioids, and anticonvulsants.

In general, analgesics should be started at low doses—usually half of the usual adult dose—and slowly titrate upward. Medications with a short half-life decrease the risk of overaccumulation while they are being titrated to steady state. Prescribing one drug at a time avoids unnecessary additive effects.

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Poor pain management may lead to decreased socialization, limited mobility, impaired posture, sleep disturbances, depression, anxiety, constipation and increased use of health care facilities.  

There is no “best way” to assess pain in the elderly, but some methods may be preferable to others. The revised verbal descriptor scale seems to be the most reliable and is generally the preferred instrument in this population — the additional words (not the pain thermometer) made the difference.

Verbal Descriptor Scale:

   The Most Intense Pain Imaginable 

   Extreme Pain 

   Severe Pain  

   Moderate Pain  

   Mild Pain 

   Slight Pain 

   No Pain 

Although the visual analog scale and verbal numeric rating scale may be the most familiar for elderly patients, the verbal descriptor scale and faces pain scales seem to be the measures preferred by those evaluating the pain

As a healthcare provider, it is imperative to consider the many factors at play in recognizing, assessing and effectively treating pain in the elderly. 

By Amber Johnson R.N. 

Amber has been a nurse for one year and works in Women’s Health as a labor and delivery nurse.  She is passionate about women’s health and, after finishing her BSN, she hopes to continue on with her master’s degree in midwifery.  She lives with her husband, Josh, and labrador retriever, Hallie, and spends all of her spare time outdoors!

References:

Wallace, M. (2001). Pain in older adults. Ann Long-Term Care. 9:50. 

Lewis, S., Heitkemper, M., Dirksen, S. (2004). Medical-surgical nursing:Assessment, and management of clinical problems. St. Louis, MO. Mosby, Inc.

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