Introduction

Pain is a common complaint of the elderly. As a person aged, the incidence and prevalence of pain increase.

Pain problems can be found in about 25% to 50% of community-dwelling elderly and 45% to 80% of nursing home-dwelling elderly.

The problem of pain is often not reported as some elderly falsely believe that pain is a normal process of aging. In addition, the presentation of pain may be atypical for elderly. Therefore, diagnosing and managing pain problems in elderly can be challenging to doctors.

Common causes of pain in the elderly:

• Bone and joints disease (e.g. osteoarthritis, rheumatoid arthritis)
• Cancer pain
• Angina/ chest pain (heart attack pain)
• Post-herpetic neuralgia/shingles or zoster pain
• Diabetic peripheral neuropathy pain
• Osteoporosis with/without fracture
• Ischemic pain of limbs/ peripheral vascular disease

Assessment of pain

Pain assessment in the elderly is a complex procedure. This process often involves doctors and healthcare professionals from different discipline (eg. primary physician, physician, neurologist, geriatrician, orthopedic surgeon, physiotherapist, occupational therapist, etc.)

After initial assessment, some of the examination includes:

• Complete history and physical examination, aimed at identifying the precise etiology of pain (may be multi-factoral).
• Going through the sites of pain, severity, worsening and/or relieving factors and the pain impact on sleep and mood.
• A screen for cognitive/memory impairment.
• A screen for depression.
• Evaluation of the patient’s level of function i.e. Activities of Daily Living (ADL) (bathing, dressing, toileting, transfers, feeding, and continence) and instrumental ADLs (use of phone, travel, shopping, food preparation, housework, laundry, taking medicine, handling finances).
• Assessment of gait and balance.
• A screen for sensory depression i.e. to examine basic visual and auditory function.

Complications

Effects of pain are more serious for older people:

• Pain can make elderly less able to function and more dependent on other caregivers.
• The elderly may lose sleep and become tired.
• They may lose their appetite and resulting in malnutrition.
• Pain may prevent elderly from interacting with others and from going out. As a result, they may become isolated and depressed.
• Pain can make elderly less active and can lead to loss of muscle strength and flexibility, making activity even more difficult and increasing the risk of falls.

Treatment

Management

After a diagnosis is made, a consensus treatment plan should be outlined that includes modalities to decrease pain perception and increase patient’s function.

A multi-disciplinary approach is recommended to investigate all possible options for optimal management, including drug therapy and non-drug therapy.

Drug therapy

During an episode of pain, it is recommended that the pain relieve medication(s) to be taken regularly (eg. every 3-6 hours) to maintain continuous freedom from pain. This is as oppose to taking pain relieve medication only when the person starts to feel the pain. Oral medications require some amount of time (half an hour to one hour) before the start of action, therefore leaving the person to be in agony of pain if not taken regularly.

As much as possible, the medication(s) recommended should be taken orally. Lastly, the sequence of trial of pain medication(s) can be upgraded from the mildest to the most potent in the following manner:

1. For mild pain, the most appropriate first choice for relatively safe pain reliever is Paracetamol (or acetaminophen).
2. For mild to moderate pain or pain uncontrolled with Paracetamol, the use of pain relievers e.g. NSAIDs is appropriate.
3. For pain not relieved by NSAIDs, or pain rated as moderate initially, a weaker opioid (e.g. codeine) is the appropriate first choice. The weak opioids may be used in combination with Paracetamol.
4. For pain not improved by the previous plan, or pain rated as severe, other stronger opioid (e.g. morphine) is selected.
5. Adjuvant medication may be used to relieve fear and anxiety in elderly patient with pain.

Non-drug therapy

Non-drug treatments e.g. heat and massage therapy, support from caregivers and family members can help older patients manage the pain and reduce the need for drugs.

For those opting for heat and massage therapy, advice from your doctor is important as it may cause more harm in people with sensory deprivation and/or fragile skin.

Alternative treatment like acupuncture may also help but it is essential to get treatment from certified practitioners.

The non-drug treatments should be combined with drug therapy to achieve effective pain relieve in the elderly.