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April 2008: Improving pain detection in older patients

How does pain present differently in older patients?

How should pain be assessed in primary care?

What is the key to providing adequate analgesia?

How does pain present differently in older patients?

How should pain be assessed in primary care?

What is the key to providing adequate analgesia?

Pain is a common, serious and disabling problem. This is especially true in older people, who are more likely to have chronic, often painful, degenerative conditions such as musculoskeletal problems.

Around 50-80% of patients aged 65 years or over living in the community experience some form of pain; 10-15% suffer significant pain and 33% report daily persistent pain.1 The prevalence of persistent pain is even higher among nursing home residents.1

Persistent pain substantially impairs quality of life, restricts mobility and social engagement and causes depression, irritability and sleep and behavioural disturbance.2 Despite this, the awareness and management of pain in older people remains inadequate,3 with less than 45% of cognitively impaired nursing home residents with significant pain receiving any analgesia.4 The consequences of inadequate pain relief are listed in table 1, below.5

41185276Pain assessment in older patients can be challenging. There is a high prevalence of cognitive impairment, with associated decline in verbal communication skills, and false assumptions that pain is an inevitable consequence of growing old and that people with cognitive impairment have a higher pain threshold.3,6

A high level of stoicism among older people often means that they suffer in silence. Older people may not report pain for several reasons, including fear that pain signals a serious disease and fear of being admitted to hospital for tests, or even institutionalised if they are unable to cope.4,6 Many older people are wary of adverse effects from medication, such as interactions, increased risk of falls and deterioration in cognitve impairment, or addiction to painkillers. Unfortunately, the latter is also a concern among many physicians and often results in analgesia being withheld.6

Effective pain management in older people requires an appreciation of its atypical presentations as well as an understanding of the pathophysiology of pain and the pharmacology of pain relief.3 It is essential that all healthcare providers develop the skills necessary to assess pain accurately and judiciously apply appropriate drug and non-drug treatment strategies.

The British Pain Society and British Geriatrics Society have developed practical guidance on pain management in older people, which should help these patients preserve their self-esteem, functional capacity and sense of wellbeing.6

Assessment

Persistent pain often has a complicated, multifactorial aetiology in older people, who may have several comorbidities.

It is relatively straightforward to identify the presence and aetiology of pain in older patients whose cognitive function is intact and can articulate well. GPs should take an accurate history and conduct a thorough physical examination, in particular focusing on musculoskeletal

41185277(ie fibromyalgia, inflammation, deformity) and neurological problems (ie hyperalgesia, weakness, paraesthesia). However, a normal physical examination does not exclude the presence of pain. See table 2,left, for key points to check in a 10-minute consultation and figure 1, attached, for an alogorithm for the assessment of pain.

Pain intensity assessment tools

It is important to use a scale appropriate for the individual and to ensure that the patient's spectacles and/or hearing aid(s) are worn and functional.5,6 A pain log or diary is recommended to document the range of words used to describe pain and the assessment tool used.3 The same tool to assess pain intensity should be used for subsequent assessments.

A systematic review comparing the effectiveness of different pain scales in older patients revealed that verbal rating/descriptor scales and numerical rating scales are the most valid and reliable in rating pain intensity in older people, including those with mild to moderate cognitive impairment. See figure 2, attached, for numerical and verbal pain rating scales.6,7

The faces scale is less effective, and the visual analogue scale appears to be the least effective method for measuring pain intensity in older people.6,8 Studies in cognitively intact older patients have shown that the faces scale has good test-retest reproducibility, but that patients were unable to put the faces in the correct order when asked to rank them. This problem was more marked in patients with cognitive impairment.6 The British Pain Society does not recommend the faces scale for general use with older patients or nursing home residents.6

Many of the standardised pain intensity assessment tools rely, to a variable extent, on abstract thinking and self-reporting, and so are less easy to use as language ability declines

(for example because of dementia or aphasia).3,6 However, it may still be possible to assess pain where language is a barrier; patients with mild to moderate cognitive impairment can be assessed with simple questions and screening tools.6 Many may acknowledge soreness, burning, discomfort or aching. GPs should also note the presence of pain behaviour (such as grimacing, groaning or guarding) during activity (such as repositioning, transfers or walking).3

Patients with cognitive impairment

41185278The prevalence of dementia in nursing home residents is more than 50% and, as language is an early domain to be affected, difficulty articulating pain is common.5 Patients with severe dementia may have altered affective responses to pain, causing them to communicate pain in ways that are challenging to carers and less easily understood (see table 3, left).5,6

Behaviours potentially indicating pain vary, not only from patient to patient but also within the same individual. Some patients present with a unique ‘pain signature': some may become withdrawn and quiet, while others become agitated.5

It is important to recognise that behavioural disturbance may be caused by pain and to avoid inappropriate treatment with antipsychotics or benzodiazepines.3

Although severe cognitive impairment and communication difficulties pose challenges to accurate pain assessment, alternative surrogate or observational approaches are available. However, interpreting nonverbal cues, such as facial expression or body movements, may be difficult, particularly in patients with Parkinson's disease or following cerebrovascular damage.5,6

Subtle changes in behaviour patterns should raise the suspicion of pain and lead to a systematic evaluation of possible causes.5,6 This often requires assistance from the patient's family or carers familiar with the patient's normal behaviour.

Family members and carers should be asked if they think the cognitively impaired person is in pain, and if so why they believe this and where they think it hurts. They should also be asked if there has been a change in the patient's behaviour (see table 3, above). It is useful to check if behaviour has been modified after a trial of analgesia, as this may suggest the pain has been resolved. However, in general, family caregivers overestimate, and healthcare professionals underestimate, the severity of pain in verbally noncommunicative patients with cognitive impairment, and neither are necessarily able to quantify the intensity of pain.3,6

Treatment

41185279The benefits of treating pain are manifold (see table 4, left). However, older patients may view analgesia with suspicion and take it reluctantly, and the use of non-drug therapies, including physiotherapy, occupational therapy, massage therapy and psychological therapy, should be considered.5 There is strong evidence that regular participation in physical activities reduces pain and enhances the functional capacity of older patients with persistent pain.3

Obviously, pain management is most successful when the underlying cause is identified and treated.

The British Pain Society recommends regular administration of analgesia for persistent pain, with breakthrough pain relief before activities known to exacerbate pain, such as transfers.6

Unless pain obviously results from inflammatory or neuropathic processes for which COX-2 inhibitors and non-opioid pain modulating agents (ie anticonvulsants) respectively are sufficient, a stepwise progression using the WHO pain ladder is recommended. This should progress from non-opioid analgesics such as paracetamol, to anti-inflammatory drugs, to neurotransmitter-modulating and membrane-stabilising drugs and opioids, while balancing the medical risks and benefits.3

If patients' pain is well controlled on co-proxamol and it is not causing side-effects they should be allowed to continue, especially if they have previously found other analgesia wanting. The MHRA position states: ‘We recognise that there is a small group of patients who are likely to find it very difficult to change from co-proxamol or where alternatives appear not to be effective or suitable. For these patients, following cancellation of the licences at the end of 2007 there is a provision for the supply of unlicensed co-proxamol, on the responsibility of the prescriber.'9

If the patient cannot swallow, analgesia can be administered rectally, by transdermal patch, by subcutaneous infusion using a syringe driver or via a nasogastric tube.

Non-selective NSAIDs are associated with a high rate of life-threatening gastrointestinal haemorrhage in older people, and COX-2 inhibitors are safer.6

Co-administration of misoprostol or a PPI may be intolerable or inconvenient.3

Analgesia should be titrated and therapeutic gains and adverse effects should be evaluated frequently to lessen toxicity and drug interactions.3

Pharmacokinetics

The alterations in pharmacokinetics and pharmacodynamics that occur with ageing are exaggerated when an older person is ill or malnourished. Thus, in general, the response to a given dose of drug is greater and the duration of effect longer in older people (and more so when they are systemically unwell or malnourished). Older people are also more vulnerable to the side-effects of all medications.

Obviously, a careful approach needs to be taken when prescribing but concerns about the alteration in dose response and metabolism that occur with ageing should not prevent the older person receiving adequate analgesia (takes the pain away, keeps the pain away, and does not cause side-effects). In general, start with a low dose, consider increasing the dosing interval and titrate the dose slowly.

It is important to review the need for, and adequacy of, analgesia and explain to the patient the nature of the pain and the rationale for its management. For example, for a painful condition that will not go away, such as osteoarthritis of the knee, regular, long-term analgesia may be required and intermittent dosing is unlikely to be effective.

Individualised therapeutic trials are usually necessary as patient responses to drug therapies differ.3 Although drug regimens should be as simple as possible, a combination of two or more therapeutic agents may afford better pain relief with less toxicity than higher doses of a single agent.3

If pain behaviours persist after excluding all other possibilities, an empirical trial of analgesia may be warranted.5 This will need careful monitoring. Paracetamol should be used initially but titration to a stronger analgesic may be necessary before ruling out pain as the aetiology for behaviour or activity changes.5

It is also important to recognise that, in addition to other comorbidities, older patients with persistent pain may also suffer significant depression that requires treatment in tandem with pain management.3

Useful information

The Cochrane Library website includes systematic reviews focusing on chronic non-cancer pain
www.mrw.interscience.wiley.com/cochrane

The World Health Organization pain ladder is available from the WHO website
www.who.int/cancer/palliative/painladder/en

Authors

Dr Jatinder K Juss
BSc MA MRCP
specialist registrar

Dr Duncan R Forsyth
MA FRCP FRCP(I)
consultant geriatrician,
Addenbrooke's Hospital, Cambridge

Figure 1. Algorithm for the assessment of pain in older people Figure 2. Pain rating scales Key points Table1pain Table2pain Table3pain Table4pain Improving pain detection in older patients

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