Key Concerns for Pain Management in Elderly Patients

Identifying symptoms of painful conditions may be more difficult with elderly patients, particularly those who are suffering from dementia or Alzheimer's.

Identifying symptoms of painful conditions may be more difficult with elderly patients, particularly those who are suffering from dementia or Alzheimer’s.

In a recent issue of the Gerontological Society of America’s What’s Hot newsletter, focused on the benefits of effective pain management in elderly patients, Deborah Dillon McDonald, RN, PhD, University of Connecticut School of Nursing, stated that “Under-treatment of chronic pain in older adults is common, contributing to unnecessary suffering” and advised that “older adults and practitioners need to work together to find optimal multi-modal pain management plans that reduce pain and avoid adverse events.”

Elaborating on the theme of pain in elderly patients being often “poorly reported, recognized and managed," Angil Tarach-Ritchey, RN, GCM, noted that despite recent efforts to improve pain management education and raise awareness of key issues among physicians and other clinicians, the profession is “still a long way off from adequate pain management in the elderly population, especially in those who can't or won't report pain,” such as patients suffering from dementia or Alzheimer’s disease.

Tarach-Ritchey identified several “physical indicators of pain in persons who cannot communicate pain,” such as “facial grimacing or moaning and yelling out, particularly with movement.” She also pointed to several non-verbal indicators such as guarding or not using an injured limb. Loss of appetite, mood changes, changes in blood pressure are also cues that can indicate a patient is suffering from pain.

She listed seven key considerations for clinicians to remember when managing elderly patients who may be suffering from pain:

  • We all have to keep in mind that pain in any form is not normal.
  • We all experience pain differently.
  • We do not and should not just endure pain without treatment.
  • Person with dementia, and others unable to communicate, will and do experience pain. Monitoring for pain on a daily basis is extremely important and should be one of the first considerations if there are noteable changes in functioning and demeanor.
  • Patients must advocate for themselves and family members for pain assessments and adequate pain control. If their health care provider doesn't take the patient’s pain seriously, that patients should seek another provider who will.
  • Patients and caregivers should always monitor and report the effectiveness of a natural or prescribed treatment. If it is ineffective, advocate for an alternative treatment that is effective.
  • Some pain medications can cause elderly patients to fall, or have hallucinations; patients and their caregivers should be advised to notify their physician immediately if there are any adverse side effects.

Several tools for assessing pain in nonverbal patients

“Pain Assessment Strategies in Older Patients,” published in a March 2011 supplement to the Journal of Pain, further underscores the negative effects of underrecognized and undertreated pain in elderly patients. With studies showing that nearly half (48%) of patients age 65 and over experience pain on a daily basis (with up to 85% of nursing home residents experiencing daily pain), undertreated pain can have severe negative consequences for this population, including “depression, anxiety, falls, malnutrition, reduced cognition, impaired sleep, functional disturbances, declines in socialization and recreational activities, increased health care costs, and reduced quality of life.” With patient verbal self-report (the “gold standard for assessing pain”) unobtainable in a substantial proportion of elderly patients (such as those suffering from cognitive impairment), clinicians look to other methods for accurately assessing pain. In addition to performing a complete medical history and physical examination, clinicians should also obtain a thorough pain history that details the characteristics of the patient’s complaint, “associated features or secondary signs and symptoms” (including intensity, quality, location, radiation, and pattern), and aggravating and relieving factors. Close attention should be paid to all nonverbal cues provided by the patient. Questions about the nature and severity of pain should include open-ended queries. Pain assessment instruments and scales, such as the Visual Analogue Scale (VAS), Faces Pain Scale (FPS), Verbal Descriptor Scale (VDS), Iowa Pain Thermometer (IPT), and Numeric Rating Scale (NRS) are also useful in this population.

Gauging the impact of pain on psychological, physical, and cognitive function is an essential component of effective pain assessment. There are several tools available to assist in this, including the Range of Motion (ROM) scale, performance of activities of daily living (ADL), Lawton Instrumental Activities of Daily Living (IADL), and the Functional Independence Measure (FIM). The Brief Pain Inventory (BPI) and the Geriatric Pain Measure (GPM) were developed for use with elderly patients “to specifically measure the impact of pain on QOL components.” There has also been a “hierarchy of techniques for assessing pain in nonverbal patients” developed and supported “in a consensus statement by the American Society for Pain Management Nursing and an interdisciplinary coalition of experts. Clinicians are reminded that “the same tools used to initially assess pain and/or specific pain-related behaviors should be used for follow-ups,” as reassessment using the same methods “is necessary to identify progress toward alleviating pain and to determine whether the older person is responding to the treatment plan.”