Elder Care In Hospital

An estimated 60-75% of people over the age of 65 report at least some persistent pain (Ferrell, Ferrell, & Osterweil, 1990, Tsang et al., 2008, as cited in Molton & Terrill, 2014). For patients awaiting transition to long term care, it is important to keep in mind that persistent pain may impact up to 80% of nursing home residents (Lynch, 2012 as cited in Registered Nurses’ Association of Ontario, 2013).  

Pain in older adults is not always understood or thoroughly assessed. As a result, pain may be undertreated in older adults. It is important to involve family or caregivers in the pain assessment because patients with cognitive impairment may not be able to verbally communicate when they are experiencing pain (AGS, 2002 as cited in Horgas, 2007).

Misconceptions amongst both older adults and health care providers can result in pain being inadequately treated or not treated at all (Registered Nurses’ Association of Ontario, 2013). Misconceptions include:

• Pain is expected as people age

• Procedures are simply painful

• Level of pain is directly proportional to the level of tissue damage (Registered Nurses’ Association of Ontario, 2013)

• Fear of addiction by prescribers and patients themselves (Guerrio, Bolier, Van Cleave, & Reid 2016)

The most frequent pain complaints among older adults are:

• Osteoarthritic back pain (around 65%)

• Musculoskeletal pain (around 40%)

• Peripheral neuropathic pain (around 35%)

• Chronic joint pain (15-25%)
  (Denard et al., 2010, Donald & Foy, 2004, Mailis-Gagnon, Nicholson, Yegneswaran, & Zuroqski, 2008 as cited in Molton & Terrill, 2014).

Assessing pain and intervening to ease, monitor, prevent and minimize it should be top priorities for a patient’s care, regardless of diagnosis or type of pain. Effective pain management is a person’s right (Jarzyna et al., 2011 as cited in Registered Nurses’ Association of Ontario, 2013) and contributes to overall quality of life.

Quality of Life

An older individual who is experiencing chronic pain is at higher risk of decreased appetite, delirium, increased irritability, confusion, depression, impaired sleep, social isolation, and functional decline because of persistent pain (Malec & Shega, 2015; Auret & Schug, 2005).

Treating pain is important because pain has pathophysiological consequences affecting the cardiovascular, gastrointestinal, immune, respiratory, musculoskeletal and neurological systems (Middleton, 2006 as cited in Registered Nurses’ Association of Ontario, 2013). Untreated acute pain may result in long-term pain (Kehlet, Jensen, & Woolf, 2006 as cited in Registered Nurses’ Association of Ontario, 2013).

Acute vs. Chronic Pain
Acute pain is a “temporary pain, time limited situation with attainable relief” (Scofield, 2018). Chronic pain has been defined by some as persistent or episodic pain that lasts so long or is so intense that it impacts the wellbeing or function of the patient (Auret & Schug, 2005). Others define chronic pain as pain that lasts longer than three months (Kaye, Baluch, & Scott, 2010).

Nociceptive vs. Neuropathic Pain
According to Arnstein (2016), nociceptive pain occurs because of acute illness, injury or inflammation associated with an injury or potential tissue damage. For example, a bone fracture. Neuropathic pain arises because of damage to the peripheral central nervous system. For example, neuropathy related to diabetes.

Psychological Pain
Psychological pain is an unpleasant emotional feeling that is non-physical.

Pain Assessment in Older Adults

A comprehensive and collaborative multidisciplinary assessment is essential to ensure optimal care needs are met. Pain assessment in older adults should include a number of components and questions. The more comprehensive the pain assessment, the higher the chance of a better pain management plan.

Components

1. Use pain rating scales that are tailored to the patient’s needs.

   • Assessing pain in individuals with cognitive impairment requires a special tool. Validated pain assessment tools are available for either the cognitively well or cognitively impaired and should be used as part of an assessment.

   • Be sensitive to hearing and language barriers.

2. Maintain an awareness of cultural differences in the way pain is expressed.

3. Collect patient/client self-reported information. If patient is unable to self-report, collect collateral information from caregivers and/or family members (if available).

4. Physical, social, mood and cognitive assessment/examination.

5. Daily assessment of pain is necessary.

6. Listen for words that may be used to describe feelings other than pain. For example, burning, ache, sore, etc.

7. Determine if cause of pain is nociceptive or neuropathic.

8. Assess personal history of past medication misuse or diversion.

9. A pain diary is useful for evaluation of interventions in chronic pain management.

Pain Assessment in Cognitively Impaired Older Adults

Questions that are an essential part of a Comprehensive Pain Assessment

1. How does the pain present (at rest, with movement)?

2. How intense is the pain (average day, when it is the worst)?

3. When did the pain begin (last week, 3 years ago, etc.)?

4. What are the characteristics of the pain (burning, stabbing? what makes it worse/better)?

5. Does the pain interfere with daily activities (appetite, bathing, sleeping, walking, cooking, etc.)?

6. Is there a change in mood (depression, anxiety) or behaviour (social isolation, guarding, aggression, grimacing) as a result of pain? 

7. What non-verbal pain cues are present when staff move them during care?

8. Does the patient/client have painful conditions such as previous bone fractures, neuropathy, post-herpetic neuralgia, gout, osteoarthritis, contractures, etc.?

9. What treatment is patient currently receiving for pain (both pharmacological and non-pharmacological)?

10. How is the patient coping with pain (exercise, restricting movement, praying, meditating, etc.)? Is this effective?

Pain is whatever the patient says it is. It is not helpful for health care providers to brush off claims of pain. It is important that health care providers use validated tool(s) when completing a pain assessment. There are a number of helpful pain scales that are available.

The following are a few validated options for use:

Guiding Principles

• Establish realistic treatment goals that are mutually agreed upon between the care provider and patient. While there is value in treating chronic pain, it rarely goes away completely. Reducing pain intensity has been shown to be a top priority for patients. Other goals may include improving function, finding a diagnosis, and avoiding medication side effects (Henry, Bell, Fenton, & Kravitz, 2017).
• Age-related changes need to be taken into consideration when contemplating pain medication choice (polypharmacy, multimorbidity). This includes physiological changes such as reduced creatinine and hepatic clearance, intravascular volume, and muscle mass. Organ volume may cause higher drug plasma levels than what one may see in a younger patient (Malec & Shega, 2015). Lower doses of pharmacological agents are usually required in older adults.
• Use of a variety of analgesic medication and techniques (also called multimodal analgesia) in acute or post-operative settings might have additive or synergistic effects. That being said, multimodal analgesia is more effective pain relief compared with single-modality interventions (Chou et al., 2016). Remember that medications might also be combined with nonpharmacological interventions for a multimodal approach.
• Around the clock pain management vs. an on-demand/as-needed approach may be appropriate in acute and post-operative settings, or in cases of persistent pain for more than 12 hours a day. Effective non-opioid analgesics around the clock can be incorporated as a part of multimodal pain management.
• Utilizing a topical agent when appropriate is ideal for older adults with localized pain. It is less likely to be absorbed systemically and cause adverse events (Marcum, Duncan, & Makris, 2016).
• Frequently monitor and readjust pain management plan based on the effectiveness and possible adverse events.

Non-pharmacological Treatment Options

Pharmacological Treatment Options

The American Geriatrics Society guideline provides recommendations on the initiation and titration of commonly used pharmacotherapies in older adults (American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons, 2009).

Topical analgesics are a particularly important treatment modality in older adults. These agents are often appropriate for localized pain and have very little, if any, systemic absorption. Topical analgesics also avoid increasing the medication burden in older adults. Patient should be instructed to not apply the topical agent on open or irritated skin areas. Marcum, Duncan and Makris (2016) detail some of the topical agents available:

Acetaminophen is recommended as a first-line analgesic for mild-to-moderate pain. It is often used in around-the-clock regimens in post-operative pain, osteoarthritic pain and other treatment settings. Recently the FDA has reduced the maximum dose to 3 grams in 24 hours. Healthcare professionals may still prescribe 4 g/24 hours at their own discretion and clinical judgment.

Potential interactions with Acetaminophen:

• Patients who have liver disease, or three or more alcoholic drinks per day should avoid or significantly reduce their dose of Acetaminophen (Malec & Shega, 2015).
• Patients on concomitant Warfarin therapy need to be closely monitored for INR prolongation while on Acetaminophen.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are an effective option for treatment of inflammatory and post-operative pain. Geriatric guidelines recommend that NSAIDs be used with caution and for shortest duration possible (2019 American Geriatrics Society Beers Criteria® Update Expert Panel, 2019). This is due to potential adverse events (GI bleeding, elevated blood pressure and cardiovascular events), drug-drug interactions (ACEi, anticoagulants) and renal insufficiency (to be avoided in patients with CrCl < 30 ml/min). This caution is relevant to both non-selective (e.g., ibuprofen, naproxen) and cyclooxygenase-2 selective inhibitors (e.g., celecoxib).

Opioids are a good treatment option for moderate to severe pain when non-opioid analgesics and non-pharmacologic interventions do not provide adequate pain relief. Potential risks of opioid medications in older adults include increased risk of adverse events (e.g., constipation, sedation, confusion, and respiratory distress), drug interactions, cognitive decline, and falls and fractures.

Key points in using opioid analgesics in older adults highlighted by Naples, Gellad and Hanlon (2016) include:

• Opioids should be initiated at 25-50% of the usual recommended dose for younger adults. For example, start at a dose of Morphine 2.5-5 mg  for an older person. The 2010 Canadian Guideline for Safe and Effective Use of Opioids for Non-Cancer Pain provides dosing of opioid medications in Morphine equivalents (Canada: National Opioid Use Guideline Group, 2010). (See Switching Opioid Form below)
• When initiating treatment in opioid-naïve patients, long-acting opioids (extended-release dosage forms, fentanyl or buprenorphine patches, etc.) should be avoided.
• Once a stable daily dose is established in chronic pain modalities, changing therapy to maintenance sustained-release opioids should be considered.
• Codeine- and Morphine-based opioid medications should be avoided in patients with reduced kidney function (< 30 ml/min) due to possible accumulation of the drug and increased risk of adverse events.
• Co-administration of opioids and other agents that impact the central nervous system (e.g., benzodiazepines, antipsychotics) can result in increased sedation and should be avoided or monitored closely.

Adjuvant drugs are administered in conjunction with analgesics to relieve chronic pain. Antidepressants and anti-epileptic medications are specifically useful for neuropathic pain. Points to consider:

• Tricyclic antidepressants (in particular amitriptyline) should be avoided in older adults due to their anticholinergic effects (confusion, dry mouth, urinary retention, and constipation) (2019 American Geriatrics Society Beers Criteria® Update Expert Panel, 2019).

• Anticonvulsants (e.g., gabapentin) should be started at a low dose and increased over 3-5 days due to possible adverse events such as lethargy and impaired balance that subside with time.

Cannabinoids lack sufficient evidence to provide recommendations for use of these agents with older adults. For up-to-date guidance, consult the Clinicians page of the Cannabis subject guide.

When contemplating pain medication administration for older adults, consider the following (Pergolizzi et al, 2008):

• What is the type of pain and how severe is it?
• What is the evidence for overall efficacy of this medication?
• What is the side effect potential of this medication?
• Time for onset of action for this medication?
• Any drug interactions? (Increased risk with polypharmacy?)
• Any potential for abuse?
• Cost and availability of this medication?
• What are the patient’s co-morbidities?
• What are our (my) treatment goals?

Patient Education Related to Pain

Some key points in education that teams need to share with older patients about their pain are (Guerriero, Bolier, Van Cleave, & Reid, 2016):

• Eliminating chronic pain is challenging 
• Mutually agreed upon and realistic goals between the care provider and patient are important
• Dispel pain treatment myths
• Use a pain diary

Health care providers caring for older adults should be knowledgeable and receive ongoing education about pain.