The Challenges of Pain Management in the Elderly

Internal Medicine World ReportJuly 2005

The Challenges of Pain Management in the Elderly

ORLANDO—Physicians are sometimes confused when a patient says, “Well, I just

hurt.” Bruce A. Ferrell, MD, of the University of California, Los Angeles, who chaired the Management of Pain Disorders in the Geriatric Population symposium at

the annual meeting of the American Geriatrics Society, pointed out that this is

not a form of denial. Instead, it may represent a different way to respond or a different

understanding of the meaning of the word “pain.” “We [physicians] would interpret somebody

who says ‘I hurt’ as having pain, but patients may say, ‘it hurts, but I don’t have

pain.’ That’s sometimes confusing and makes assessment more difficult,” Dr

Ferrell explained. “And elderly patients often have trouble with memory—they

have cognitive impairment, Alzheimer’s disease, multiple strokes. Those kinds of issues

make pain assessment particularly difficult. And yet, they suffer a lot from pain.”

Dr Ferrell told IMWR that physicians should keep in mind that elderly patients

are more susceptible to analgesic side effects and are more likely to suffer serious pain problems than younger patients. They also tend to have more problems with, and

respond differently to, most pain-relieving therapies compared with younger patients.

When prescribing for the elderly, a physician’s choices are determined by which

drugs are the safest and yet still effective for the management of their pain. Elderly

patients tend to have multiple issues with painkillers, because many of these drugs

have anticholinergic side effects or long halflives that can cause drug accumulation, sedation,

or other side effects that can be more troubling than the pain itself. Moreover,

geriatric patients are more likely to have multiple causes of pain and may have 2 different

kinds of pain at the same time. When it comes to determining the source

of pain, Dr Ferrell emphasized that it is important for the physician to distinguish

between neuropathic and nociceptic pain. “Nociceptic pain is from stimulation of pain receptors in the skin or any tissue, such as arthritis or cancer pain. Neuropathic pain results from a disease or disorder of the nervous system in which the nerves are sending false messages to the brain, saying that they are in pain when actually no real pathology exists at the time.”

The use of opioids for the relief of severe pain has a long history of controversy,

largely related to what Dr Ferrell calls “the myths and misconceptions about drug

addiction and illicit drug use.” In reality, he says, the fear of drug addiction is overstated,

especially in the elderly. Actually, some geriatric patients might be better off taking

opioids than nonsteroidal anti-inflammatory drugs (NSAIDs) because of the risks

associated with the latter. “We do not necessarily believe that opioids

are the last drug of choice, but in some of our patients they may actually be safer

than high-doses of NSAIDs over long periods of time.”“There are some new opioids that are

probably going to come on the market soon, and they may be helpful in terms of our

armamentarium for certain kinds of patients. The important thing is that we improve the

patients’ quality of life, and pain management is integral in making patients have a

good quality of life,” Dr Ferrell said.

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