SOAP. – Pain Assessment and Management in the Aging Population

Pain Assessment and Management in the Aging Population

Moya Cook, Jill C. Cash, and Kathleen Bradbury-Golas

Definition

A.Persistent pain occurs quite frequently in the elderly population. However, pain is not a normal part of aging. Chronic pain is defined as having sensory/emotional changes with experience of tissue change/damage for longer than 3 months. Uncontrolled chronic pain may lead to a downward spiral for the patient, progressing to alterations in physical and mental health status. Inadequate assessment and management of chronic pain may lead to a decrease in the quality of life for all patients.

Common Pain Syndromes

A.There are many common pain syndromes that are present in older patients. Assessing for these unidentified pain syndromes may enhance discovering the source of pain for the patient. Common pain syndromes experienced by elderly patients include fibromyalgia, gout, osteoarthritis, unidentified fractures, neuropathies, and vitamin deficiencies, such as vitamin B12 deficiency.

Incidence

A.Elderly men and women are the fastest growing population. It is estimated that by the year 2040, there will be more than 1.3 billion people worldwide older than the age of 65. In the United States alone, there will be over 80 million people living in this age group.

Pathogenesis

A.Studies indicate that pain sensitivity changes and pain threshold increases with aging. Therefore, the absence of reportable pain does not mean that pain does not exist in the elderly population. As one ages, the number of neurotransmitter cell receptors in the brain diminishes as brain tissue begins to atrophy. This loss of neurons has a direct impact on pain transmission, which ultimately increases pain tolerance and disguises the presence of pain in the elderly.

Predisposing Factors

A.Aging adult.

B.Barriers to effective pain assessment:

1.Cognitive, language impairments.

2.Comorbid chronic condition (depression, anxiety, agitation, illness, dementia, psychological disorders, memory disorders, etc.).

3.Medications taken by the patient.

4.Ineffective communication to the provider.

5.Ineffective assessment by the provider.

6.Noncompliance with medication regimen.

Subjective Data

A.On the initial exam, a comprehensive history is imperative when assessing for pain. Communication is a key ingredient when assessing for pain. Hearing loss, vision loss, and the inability to fill out documents (pain scales) are a few components of the assessment that can interfere with a successful interview. Adjustments should be made to ensure that communication among the patient, family/significant other, and provider is clear. Patients who are not able to provide verbal information should be assessed for behaviors and physical signs of pain. Physical signs of pain may include grimacing, moaning, silence, poor eye contact, and so on. Behaviors that may be an indicator of pain may include anxiety, agitation, confusion, depression, and isolation. Other factors to consider when assessing a patient for pain include the patient’s age, past medical history, surgical history, current medications, current cognitive status, and functional status. A focused history will assist in establishing a baseline status for the patient:

1.Assess for communication/cognitive impairments that may interfere with the assessment. Consider communication factors, comorbid conditions/illnesses, and current medications.

2.Assess the current mood and physical state of the patient (depression, anxiety, anger, illness).

3.Have the patient describe the duration of pain and what time of day symptoms begin.

4.Ask the patient to describe the pain, for example, crushing, stabbing, or burning.

5.Ask the patient where the sensation begins and in what direction it radiates. Does pain come and go, or is it constant? What makes pain worse? What makes pain better?

6.Have the patient rate pain on a scale of 0 to 10, with 0 being no pain.

7.Ask the patient to complete a functional status form to assess functional abilities. Identify impairments of activities of daily living (ADLs) and note limitations.

8.Ask what medications/treatments have been used in the past for pain. Was pain improved?

9.Inquire regarding family/social support, financial resources, and concerns the patient may have regarding social complexities.

Physical Examination

A.Start with vital signs: Check temperature (if applicable), pulse, respirations, and blood pressure.

B.Inspect:

2.Inspect site of pain for swelling and erythema.

C.Palpate:

1.Palpate specific sites of noted discomfort/pain.

2.Palpate adjacent joints/areas to site of discomfort. (Pain may also be caused from referred pain. A thorough exam of surrounding joints/tissues should be assessed.) Note inflammation, change in skin temperature (warm/cool), and pain with palpation.

3.Perform a complete musculoskeletal exam, concentrating on the site of pain. Assess range of motion, gait, and mobility. Evaluate strength, noting symmetry of strength, and/or weakness.

4.Perform a neurological exam on sites involved.

D.Auscultate:

1.Conduct a complete heart exam, checking for dysrhythmias.

2.Conduct a complete lung exam.

3.Auscultate abdomen, noting bruits if present.

E.Mental status:

1.Assess for confusion, agitation, change in personality, anxiety, and so forth.

Diagnostic Tests

A.Perform a Mini-Mental State Exam (MMSE) if indicated. This form is available at www.ihpa.gov.au/sites/g/files/net636/f/publications/smmse-tool-v2.pdf.

B.Perform a functional status assessment. There are many instruments that can be used; examples include the Instrumental Activities of Daily Living Scale, the 10-Minute Geriatric Screen, and the Katz Independent Activities of Daily Living. A provider resource for assessing functional status can be found at hmsa.com/portal/provider/PRC_Guide_COA_Functional_Status_Assessment.pdf.

C.Perform the Timed Up and Go test to assess mobility. This form is available at www.cdc.gov/steadi/pdf/TUG_Test-print.pdf.

D.Assess for pain using a valid method of testing for elderly patients. The Verbal Descriptor Scale (VDS) is recommended for assessment in the elderly patient. Other available tools include the Faces Pain Scale and the Numeric Rating Scale. A listing of validated clinically tested tools can be found at www.practicalpainmanagement.com/resource-centers/opioid-prescribing-monitoring/list-clinically-tested-validated-pain-scales.

Plan

A.General interventions.

The primary goal is to identify the source of pain. Once the source is noted, then measures to improve pain should be performed.

B.Patient teaching:

1.Educate the patient regarding the source of pain.

2.Discuss possible sources of improving pain, according to the diagnosis.

3.Depending on the source of pain, consider nonpharmacological treatments to improve pain.

C.Special elderly considerations for pain management:

1.Nonpharmacological treatments: Such treatments may include physical therapy, aquatic therapy, exercise, chiropractic treatments, massage, acupressure, acupuncture, transcutaneous electrical nerve stimulation (TENS), guided imagery, relaxation, hot/cold therapy, and so forth.

D.Pharmaceutical therapy:

1.Body fat, total amount of water/fluid in the body, poor nutritional status, and muscle mass all impact drug metabolism. There is a heightened sensitivity to adverse effects that results from physiologic changes, drug interactions, and drug–disease interactions.

2.Medications, such as diuretics, may influence the impact of drug distribution in the body. These factors should be considered when prescribing medications in the elderly:

a.Some changes affected by these components include onset of action, availability of the drug, and excretion of the drug.

b.Use caution when prescribing medications and repeating the dose if no response is perceived. Repeating the drug dose to obtain therapeutic results can cause adverse events and/or overdose.

c.If the drug has a slow onset, it may build up in the body and cause an overdose of the medication.

d.Aging is associated with higher steady state concentrations of water soluble drugs and increased half-life of fat soluble drugs. Therefore, when prescribing medications to elderly patients, all medications should be started at the lowest dose possible and titrated up slowly as tolerated. Lower doses are better tolerated and potentially will lead to fewer side effects.

3.Refer to the previous section on Chronic Pain for Modalities and Assessment for Pharmacologic Agents.

4.For special considerations with specific pain medications, please refer to Table 6.1:

a.Nonopioids: Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) should be discussed and considered for the treatment of mild pain. Assess liver and kidney function prior to administering these medications:

i.Acetaminophen: Contraindications to acetaminophen include liver failure, hepatic insufficiency, and chronic alcohol use. The maximum recommended dose of acetaminophen is 2 g/24-hr period, which includes all Tylenol products and combination medications that include Tylenol.

ii.NSAIDs: Contraindications to NSAIDs include peptic ulcer disease, chronic kidney disease, and heart failure. Monitor closely if the patient is taking other medications that may interact with the NSAID, such as corticosteroids and selective serotonin reuptake inhibitors (SSRIs). Elderly patients should only use one NSAID at a time. Advise the patient to avoid using over-the-counter NSAIDs, along with prescribed NSAIDs. Elderly patients should also be advised to use a proton pump inhibitor along with the NSAID to protect the gastrointestinal system. Patients taking aspirin should not use ibuprofen while also taking aspirin. Patients prescribed these medications should be closely monitored for gastrointestinal problems (ulcers, gastroesophageal reflux), prolonged bleeding times, and adverse change in kidney function. Monitor the current use of other medications (aspirin, NSAIDs, proton pump inhibitors, Coumadin, etc.) that would interact with these medications.

TABLE 6.1 Pain Medications

Classification	Examples	Special Administration/Dosing Considerationsa
Acetaminophen	Acetaminophen	Contraindications to acetaminophen include liver failure, hepatic insufficiency, and chronic alcohol use (active/present). Do not exceed 4 g in healthy adult. Do not exceed 2 g in healthy elder patient.
NSAIDs	Ibuprofen Naproxen Aspirin Voltaren Meloxicam Indomethacin	Contraindications to NSAIDs include peptic ulcer disease, chronic kidney disease, and heart failure. May prolong PT. Note potential interactions with corticosteroids and SSRIs. Take only one NSAID at a time; do not use with aspirin. Consider a PPI. Note any flu-like symptoms when

		using aspirin in adolescents—because of risk of Reye’s syndrome.
NSAIDs, COX-2	Celecoxib	Use with caution because of cardiac risks (stroke and MI). Do not exceed 400 mg/d. Celecoxib is contraindicated in patients with sulfa allergy.
Tramadol (considered weak opioid)	Tramadol	Be aware of potential acetaminophen or NSAID toxicity with concurrent use of opioids. Be aware of the interactions with the use of SSRIs and risk of serotonin syndrome and seizures.
Topical agents	NSAIDs, lidocaine, ketamine, capsaicin	Begin with low dose and increase as tolerated. Lidocaine patches—postherpetic neuralgia. NSAIDs—localized nonneuropathic pain. Capsaicin—regional pain syndromes.
Corticosteroids	Prednisone Methylprednisolone Cortisone	Tapering for short-term use as indicated. Used for neuropathic pain and pain associated with inflammatory changes or metastatic bone pain. Not for long-term use. Avoid use in the elderly due to high side effect risk.
Muscle relaxants	Cyclobenzaprine Carisoprodol Methocarbamol Baclofen Metaxalone	Use in conjunction with NSAIDs or separately if NSAIDs are ineffective. High fall risk as muscle relaxants cause drowsiness and sedation.
Stronger opioids (short acting)	Codeine Hydrocodone Oxycodone	Begin low with short acting only. Increase over time. Avoid morphine in patients

	Morphine	with renal insufficiency. Sustained release formulation only for constant pain and should be recommendation of pain specialist. Be aware of potential acetaminophen or NSAID toxicity with concurrent use of opioids.
Neuropathic Pain
Tricylclic antidepressants	Amitriptyline Imipramine Doxepin Nortriptyline Desipramine	Begin low; reevaluate and increase every 4–7 days. ECG prior to starting therapy. Use with caution in patients with cardiac issues, especially conduction abnormalities. Avoid amitriptyline, imipramine, and doxepin in the elderly due to higher side effect risk (anticholinergic effects).
SNRI depressants	Duloxetine Venlafaxine Milnacipran	Duloxetine is a P450 2D6 isoenzyme inhibitor but only one approved by FDA as an analgesic.
Anticonvulsants	Gabapentin Pregabalin Carbmazepine	Gabapentin and pregabalin usually well tolerated.

a All medications should be checked for use during pregnancy and lactation prior to prescribing.

FDA, Food and Drug Administration; MI, myocardial infarction; NSAID, nonsteroidal anti-inflammatory drug; PPI, proton pump inhibitor; PT, prothrombin time; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor.

b.Opioids: Opioids may be considered for the treatment of moderate to severe pain when nonopioids are not effective. Proper education regarding the use of these medications is necessary to avoid misconceptions regarding the use of these drugs. Educate the patient that opioids are safe medications when used properly as prescribed and that with proper use addiction can be prevented:

i.Opioids that should not be used in the elderly patient include meperidine and propoxyphene. These agents may cause central nervous system toxicity if poorly metabolized by the liver.

ii.Opiates have a higher risk of falls and the patient should be educated on this possibility.

c.Other medications:

i.Anticonvulsants, such as gabapentin, have been used successfully to treat neuropathic pain. Starting doses should be low and gradual titration upward can eliminate side effects and be used successfully to treat pain. Studies have shown that doses from 2,400 to 3,600 mg/d decrease pain and improve mood and sleep disturbance:

•Tricyclic antidepressants (TCAs): Nortriptyline has been shown to be successful in treating pain in elderly patients. Use caution in patients with known cardiac conditions. Consider ordering a baseline ECG prior to beginning therapy. Avoid use if cardiac/conduction abnormalities are present. The starting dose should begin low, and a gradual increase in dose every 4 to 7 days should be prescribed as tolerated. Amitriptyline, imipramine, and doxepin should be avoided in the elderly due to a higher risk of side effects.

ii.Local anesthetics: Pain patches may be used with discretion. Lidocaine patches are useful for postherpetic neuropathy. Other pain patches may also be trialed, beginning at a low dose and titrated as tolerated. Topical NSAIDs may be used for localized nonneuropathic pain. Capsaicin and menthol topical agents have been shown to improve regional pain syndromes. Epidural injections have also been found useful in alleviating pain in older adults.

iii.Corticosteroids: Steroids may be used for neuropathic pain and pain associated with inflammatory changes or metastatic bone pain. However, great caution should be used in treating patients with steroids. Long-term use is not recommended. Significant side effects with the use of steroids can occur in the elderly population in a very short period of time (such as muscle wasting, hyperglycemia). Consider other alternatives for pain control instead of steroids for elderly patients.

d.Cancer pain: The World Health Organization (WHO) recommends around-the-clock pain treatment for patients diagnosed with cancer. Cancer treatment strategies include the following:

i.Acetaminophen is the first-line treatment for mild pain.

ii.NSAIDs are recommended for second-line therapy for mild to moderate pain.

iii.Mild opioids (codeine, hydrocodone, propoxyphene, and oxycodone) are recommended for moderate pain and pain not responding to NSAIDs.

iv.Morphine may be used for severe pain and pain not responding to mild opioids. Other alternatives to morphine include hydromorphone, fentanyl, and methadone.

v.Consider adding additional medications for severe pain complicated by anxiety/mood disorders and not controlled on a single agent. Common medications that enhance the effects of analgesics include antidepressants, anticonvulsants (gabapentin), muscle relaxants, antihistamines, corticosteroids, topical creams/gels, antiarrhythmics (beta blockers), and alpha-2 adrenergic agonists (clonidine).

Consultation/Referral

A.Refer all patients to a pain management specialist if considering long-term pain management.

Individual considerations

A.Geriatrics:

1.Special consideration must be taken when treating the geriatric patient for acute pain. Failure to treat geriatric patients for pain is inhumane and can increase delirium in this population. Physiological changes, such as decreased body mass, hepatic dysfunction, and renal dysfunction, can cause increased serum drug concentrations. It is appropriate to begin pain medication at 30% to 50% less than the regular adult dose and titrate until pain is relieved.

2.Anti-inflammatory medications are not recommended in this population due to the risk of compromised renal function and increased risk of gastrointestinal bleeding.

3.Research indicates that questioning geriatrics about pain at night and difficulty performing activities of daily living (ADLs) is an efficient way of identifying older adults that are vulnerable to developing depression illness.

4.Randomized controlled trials found that older adults taking opioids for pain experienced only small amounts of relief and improved function, and that adverse effects were three times more likely to occur. Common opioid-induced symptoms included constipation, drowsiness, nausea, headache, and confusion. Most of those effects placed the elderly patient at greater risk of falls, which could lead to serious injuries.

5.The National Institutes of Health discovered that 53% of older adults surveyed reported acute pain in the last 3 months; and 75% of the participants listed pain in greater than or equal to two locations.

6.Integrative approaches such as yoga, massage, or chiropractic manipulation might be too strenuous for geriatrics. Tailor interventions to the individual and assess the patient for osteoporosis before recommending high-impact exercises or aggressive alternative physical activities.