Dilemmas: Recognition and treatment of pain in elderly people

For further information on the role of opioids in chronic pain see: Understanding the role of opioids in chronic non-malignant pain bpac^nz, October 2018

In this article

• Chronic pain is often under-treated in elderly people
• Reasons for under-treatment
• Recognition of pain in elderly people
• Drug treatment of pain in elderly people
• Other treatments for specific pain syndromes
• References

In this article

Chronic pain is often under-treated in elderly people

Chronic pain affects between 20–50% of elderly people and is more common in women. However, pain is often unrecognised, treated sub-optimally or not treated at all.^1,2

Pain may significantly reduce quality of life and lead to depression, anxiety, increased suicide risk, increased dependence, reduced appetite, impaired gait, sleep disturbances and other problems.¹

Reasons for under-treatment

There are many reasons why pain may be unrecognised or under-treated

• Disclosure. Patients do not or are reluctant to disclose pain. For example, an older person may perceive that pain is “normal”. Elderly people often view pain as being less important than other medical problems.
• Poor communication. Cognitive impairment, hearing and speech problems may lead to poor pain assessment in elderly people. One study showed that people with cognitive impairment were prescribed less opioids by doctors and administered less opioids by nurses.⁴
• Polypharmacy concerns. Doctors may be reluctant to add another drug to an existing regimen due to concerns about interactions and adverse effects.
• Inadequate risk/benefit analysis. Using anything other than a simple analgesic may be mistakenly viewed as being too risky due to adverse effects and the possibility of drug related harm. For example, the use of an opioid often raises concerns about tolerance dependence, addiction and safety. This level of pain control may be necessary and the benefit outweighs the risk of adverse effects.

Recognition of pain in elderly people

Elderly people may not report pain

Pain may manifest as inactivity, agitation, unexplained decreased function or a lack of sleep. Studies show that older people may not mention pain without being prompted. Asking elderly people or their carers about pain and using an appropriate pain rating scale is a useful way of identifying people who may have undiagnosed pain.

Drug treatment of pain in elderly people

A good history will aid good management

Make a firm diagnosis of the reason for the pain. This can be difficult but management of the underlying disorder may be necessary. For example, spinal stenosis can cause excessive pain and decreased function and surgery may be helpful. Knowing the diagnosis and prognosis helps with decisions about long term management.

If the diagnosis is in doubt and pain is difficult to manage ask for help from a pain specialist or relevant diagnostician.

Identifying previous analgesic use, determining effective treatments, how previous treatments were taken, and if any side effects were experienced, can help to determine the appropriate analgesic and the correct dose.

Principles of analgesic use in elderly people

• Start low, go slow

A low initial dose, followed by slow titration to response, careful monitoring and regular review helps to optimise safe and effective drug therapy if indicated.

• Review and monitor use of analgesics regularly.

Effective monitoring involves not only measuring pain relief and adverse effects, but also monitoring functional status and quality of life. Regular review to adjust dose can result in more effective control of pain and minimise adverse effects.

• Good education is the key

Good education about the most appropriate way to use analgesics is essential to gain effective pain relief for elderly people. This is particularly the case with opioids.¹ A study investigating pain in arthritis found that self management improves pain control.⁵

Regular analgesic treatment preferred to ‘as required’ treatment

Regular analgesia is more effective than waiting for pain to break through. Adherence problems can be addressed by stressing the importance of regular doses to patients or caregivers.

Paracetamol is an effective analgesic in many cases, especially if given regularly instead of ‘as required’.

Opioids are effective for non-malignant pain

There is often a reluctance to use opioids for non-malignant pain but opioids can be very effective in managing other chronic pain conditions such as neuropathic pain if alternative agents have been unsuccessful.¹

NSAIDs are effective and may be safe in short courses for acute exacerbations of inflammatory conditions. However, they are no safer than opioids and may in fact pose greater long term risks in elderly people than the appropriate use of opioids.⁶

International guidelines state that “opioid treatment should be considered for both continuous neuropathic and nociceptive pain if other reasonable therapies fail to provide adequate analgesia within a suitable timeframe.” ⁷

Codeine is normally used as initial therapy when opioids are indicated. Stronger opioids such as morphine or dihydrocodeine may be indicated for non-malignant pain that has not responded to other analgesics. Regular use of opioids is more effective for controlling pain than waiting for pain to break through.

Adverse effects of opioids can be minimised and managed

Adverse effects can be minimised by starting with a low dose and slowly titrating to the optimal analgesic effect. Using the lowest effective dose can help minimise dose related adverse effects such as constipation and sedation. Constipation is often an inevitable side effect of opioid treatment and can be managed with a stimulant containing laxative (senna or bisacodyl, see Constipation BPJ 9), increased fibre, water and exercise.

Opioids increase the risk of falls. Those using them benefit from falls prevention strategies such as lower leg strengthening and balance retraining or home hazard assessment and modification.

Alternatives for neuropathic pain

Tricyclic antidepressants and anticonvulsants can be effective for neuropathic pain. These drugs interfere with the pain pathway and can make disabling pain bearable.

While they are effective they may cause sedation and/or postural hypotension and can increase the risk of falls. This can be minimised by using low doses. Amitriptyline is commonly used for neuropathic pain, however nortriptyline is equivalent and may be preferred as it is less sedating and causes less postural hypotension.⁸

Some analgesics are best avoided

• NSAIDs and COX-2 inhibitors can have adverse effects on renal function, particularly in elderly people. They are best avoided unless they are specifically indicated such as for people with bony secondaries or acute inflammatory pain. In those who need them, it is appropriate to use the lowest effective dose, review regularly and monitor renal function. NSAIDs and COX-2 inhibitors increase the risk of drug interactions therefore it is appropriate to review other medication before initiating therapy.
• Dextropropoxyphene with paracetamol is commonly prescribed in elderly people but the combination has negligible, if any, analgesic benefits over regular paracetamol. Dextropropoxyphene is best avoided as it causes sedation, dizziness, increases fall risk and interacts with many other drugs (see Snippets).
• Pethidine is best avoided in elderly people as it has a toxic metabolite which can accumulate with impaired renal function.
• Tramadol has been associated with early reports of hallucinations and confusion.⁹ This may be more of an issue in older people because of higher plasma concentrations than in younger people.¹⁰

Other treatments for specific pain syndromes

For some causes of knee pain, including osteoarthritis, exercise can be as effective as regular pain relief. Combinations of exercise, supports and strapping, TENS (Transcutaneous Electric Nerve Stimulator) and physiotherapy have anecdotal support in pain control. Each patient will respond to pain treatments in differing ways and trying different therapies can help in pain management.

Referral to a pain clinic

This may be necessary and should be offered if the cause of pain is untreatable and the pain is unmanageable with standard approaches.

Often appropriate management of depression will enable pain to be more easily controlled. An emphasis on self management techniques empowers the patient to increase function while managing pain.