1. Use numerical and verbal rating scales to assess pain in older people
Assessment of pain is always challenging, but the range of pain assessment tools that have been validated in the literature is improving. Use of verbal descriptors – such as ‘none’, ‘mild’, ‘moderate’, ‘severe’ -and numerical rating scales are well documented as being appropriate for the older population. Guidelines for the assessment of pain in the older population are being updated this year by the British Pain Society and British Geriatric Society.
2. Use the Abbey or Doloplus scale in patients with dementia
The Abbey or Doloplus are tools which are useful for assessing patients with reduced levels of cognitive ability or communication difficulties, such as those with dementia. These scales are gaining more evidence in a variety of settings.
3. Don’t overlook pharmacological treatment options because of concerns about potential side effects
Advancing age should not be a barrier to considering pharmacological treatment options for pain – Having said this, there are surprisingly few studies examining the use of analgesics in older people specifically. Generally, younger populations have been used and the results then extrapolated to older people – this can be problematic because of the physiological changes in aging and the impact of comorbidities. Consider lower initial doses and titrate more slowly than you may in younger patients to minimise side effects.
4. Try paracetamol first line
Paracetamol is the first-line pharmacological treatment for persistent pain in older people, particularly for musculoskeletal pain as it has good efficacy and relatively few side effects. Before considering alternatives, recommend regular use.
5. Be cautious with NSAIDs
NSAIDs must be used with caution in older people, and for the shortest duration at the lowest dose. A PPI should be coprescribed and the patient should be closely monitored for renal and cardiovascular side effects, and drug or disease interactions.
6. Be aware that tricyclics and anti-epileptic drugs are often poorly tolerated by older people
For neuropathic pain, drugs used such as tricyclic antidepressants and anti-epileptic drugs do have demonstrated efficacy, but tolerability and adverse effects limit their use with older people.
7. Consider interventional therapies, especially in patients with localised or regional chronic pain
Pain in the older population tends to affect the knees, hip and back. When pharmacological treatments are ineffective or not tolerated, interventional therapies should be considered, especially in patients with chronic pain. Intra-articular corticosteroids are recommended in osteoarthritis of the knee although there is no evidence for their efficacy in other joints in older people. Facet joint interventions may be beneficial for both cervical and lumbar pain. There is some evidence for epidural steroid injections in patients with spinal stenosis, but this is not strong enough to support their use in radicular pain or sciatica.
8. Psychological interventions may be used as an adjunct to medication
Psychological factors often influence how patients respond to, and cope with, pain. Psychological interventions can help to modify beliefs and attitudes. Few studies have focused on older adults but cognitive behavioural therapy may be effective in decreasing chronic pain, improving disability and mood.
9. Aim to customise exercise programmes to the patient’s needs and capabilities
Evidence supports the use of exercise programmes that comprise strengthening, flexibility and endurance activities. They increase physical activity, improve function and pain. The choice of exercise depends on patient preference and programmes should be customised to individual capacity and need. There are lots of options, including progressive resistance exercise, walking, water-based exercise, and adaptations of tai-chi and yoga.
10. Consider complementary therapies in patients with osteoarthritis or musculoskeletal pain
Complementary therapy, for example acupuncture, transcutaneous electrical nerve stimulation, and massage, should be considered – although the evidence is limited. Acupuncture applied singularly or in combination with other modalities reduced pain and improves quality of life in patients with osteoarthritis. Percutaneous electrical nerve stimulation combined with physiotherapy reduces pain and self-reported disability for up to three months. Similarly, conventional TENS and massage can be used for relief of musculoskeletal pain.
Dr Aza Abdulla is a consultant physician with a specialist interest in elderly care at South London Healthcare Trust. He participated in the production of the upcoming national guidelines on management of pain in older people.
This article was written with help from Professor Pat Schofield, professor of nursing at the University of Greenwich and Professor Roger Knaggs, associate professor in clinical pharmacy practice at the University of Nottingham.
Schofield P (ed) et al Guidelines for the management of pain in older adults. March 2013. Age and Ageing.