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Chapter 13

Pain

Is a common experience for many older adults

Is not an expectation of aging

Pain is under recognized, highly prevalent, and undertreated among older adults.

Degenerative changes, musculoskeletal changes, and pathologic and comorbid conditions from disease or injury lead to pain in older adults.

Pain

Pain is “Whatever the experiencing person says it is, existing whenever he or she says it does” McCaffery (2000)

“A subjective, personal, unpleasant experience involving sensations and perceptions that may or may not relate to bodily or tissue damage” Aronoff (2002)

Pain is individual and may be very different for different persons with the same disease or injury.

Defining Pain

Acute pain: rapid onset and relatively short duration and a sign of a new health problem requiring diagnosis and analgesia

Treat underlying cause—short-term analgesia

Chronic or persistent pain: continues after healing or is not amenable to a cure; usually has no autonomic signs and is associated with longstanding functional and psychologic impairment

Pain Classification

Somatic pain—well defined. It may be aggravated by movement, due to articular disorders, deep and aching, may be sharp

Visceral pain—caused by organ stretch, inflammation or ischemia, diffuse and not well defined, may be referred, intense pressure, a deep squeeze, or dullness

Nociceptive Pain

Results from a pathophysiologic dysfunctional process involving the peripheral or central nervous system

Do not respond as predictably to analgesic therapy as nociceptive types of pain

Includes paresthesias (the tingling, pins and needles sensation), burning, lancinating (stabbing, cutting, shooting)

Responds to drugs such as tricyclic antidepressants (TCAs), anticonvulsants, or antiarrhythmic drugs

Neuropathic Pain

Mixed or unspecified pain has unknown mechanisms, treatment is unpredictable requiring more trials of different approaches.

Other types of pain can be caused by conditions such as conversion reaction or psychological disorders, may benefit from specific psychiatric treatments.

Mixed or Unspecified and Other Types of Pain

50% of community-dwelling older adults experience significant pain problems.

70%–80% of nursing home residents have substantial pain that is undertreated.

Older adults commonly report less pain because:

Do not want to be complainers

Fear more tests and medicines

Fear losing their independence

Scope of the Problem of Pain

Depression, anxiety, decreased socialization, sleep disturbance, decreased or impaired ambulation, prolonged recovery periods, increased use of health care resources, health care use and costs, and premature death

Decreased ambulation, impaired posture, sleep disturbance, anxiety, and impaired appetite in nursing home residents

Incontinence and constipation are also related to unrelieved pain.

Consequences of Unrelieved Pain

Listening to older adults

Relief from pain

Control of chronic disease conditions causing pain

Maintenance of mobility and functional status

Promotion of self-care and maximum independence

Improved quality of life

Goals for Pain Management

Three components of nervous system cause the sensation and perception of pain.

Afferent pathways (reception)

Nociceptors found on the skin

Central nervous system (perception)

When pain stimulus reaches the central nervous system

Efferent pathways (reaction)

Interpretation is relayed back through peripheral nervous system (efferent) pathways.

Pathophysiology of Pain

Belief that pain is a natural occurrence of aging, and chronic disease

Underreporting of pain by older adults

Inadequate access to diagnostic services

The nurse’s lack of knowledge regarding adequate pain assessment

Barriers to Effective Pain Management

They may fear the meaning of pain and its implications of worsening disease and possible death.

Patients experiencing cancer-related pain may believe it is a natural outcome of cancer and cannot be relieved.

Barriers to Effective Pain Management in Older Adults With Cancer

Asses on a scale of 1–10 scale

Breathing

Negative vocalization

Facial expression

Body language

Consolability

Persons With Dementia

Assessment is essential in differentiating acute life-threatening pain from longstanding chronic pain.

Includes thorough history and physical examination

Use the general principles on pain assessment from American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons (2002)

Be aware of cultural differences related to pain management

Pain Assessment

Numeric pain rating scales

Visual analog scales

Descriptive pain intensity scales

Pain diaries

Pain logs

A patient’s report of pain should also be evaluated for its intensity and the amount of distress it causes.

Pain Assessment Tools

Address: the onset, location, duration, intensity, characteristics, aggravating and alleviating factors, and self-treatment or other prescribed treatments that either helped or did not help

P, Q, R, S, T, U mnemonic

Comprehensive examination of the musculoskeletal and nervous systems

Evaluate for functional impairment

History and Physical Examination

Evaluation of quality of life as pain influences all dimensions of an individual’s quality of life.

Evaluation for depression since high incidence of depression associated with chronic pain

Geriatric depression scale

Additional Evaluations

The nurse has just started a hospital job where the majority of her patients are older adults. It is important that the nurse remember which of the following regarding older adults and pain? (Select all that apply.)

They may have several chronic illnesses that cause them pain.

They tend to overuse pain medication.

They believe pain is natural outcome of cancer.

When they are confused, they may not respond pain in the usual way.

They do not understand pain scales.

Quick Quiz!

ANS: A, C, D

Answer to Quick Quiz

Medications play an important role.

Nurses must be knowledgeable of the physiologic changes of aging that can alter drug absorption, metabolism, and excretion in the older adult.

Changes, especially those in liver and renal function, can increase the risk of accumulation of lipid-soluble drugs.

Analgesic drugs—classified as nonopioid analgesics and opioid analgesics

Pharmacologic Treatment

Nonopioids

Mild opioids (codeine)

Strong opioids (morphine)

Adjuvant drugs for anxiety or increased pain

Medications should be given around the clock.

Treating Cancer Pain

First-line approach to pain management

Acetaminophen (Tylenol), ibuprofen (Motrin, Advil), and naproxen (Naprosyn, Aleve)

Block pain by inhibiting pain reception at local level

Acetaminophen is drug of choice for musculoskeletal pain; does not affect platelet levels.

Maximum dosage is 3,000 mg/24 hours.

Nonopioid Analgesics

Effective for treating mild to moderate arthritic pain and other inflammatory disorders

Have been associated with stomach ulcers, renal insufficiency, and a tendency to bleed

The most common complaint associated with NSAIDs is indigestion, which may be reduced with antacid use or food consumption.

Avoided in high doses, for long periods, in presence of abnormal renal function, history of ulcer disease, or bleeding

Nonsteroidal Antiinflammatory Drug (NSAID)

Mild to moderate pain poorly tolerated or inadequately managed with mild analgesic, consider using an opioid analgesic

Start low, go slow

Problems with opioids usually involve those with long half-lives.

Moderate to severe pain can be relieved with hydrocodone, oxycodone, hydromorphone, oxymorphone, or immediate-release morphine.

Opioid Analgesics

Nausea, vomiting, constipation, and urinary retention

Older adults are more sensitive to sedation and respiratory depression especially opioid naïve.

Never give fentanyl patch to opioid naïve.

Constipation is of particular concern in older patients because many of them have preexisting bowel conditions so start on a bowel program when initiating opioid treatments.

Opioid Analgesic Side Effects

Medications without intrinsic analgesic properties

Anticonvulsants, antidepressants, and some sedatives

Anticonvulsants help control painful conditions: postherpetic neuralgia, diabetic neuropathy, and phantom limb pain.

Alter or modulate the perception of pain

Can be used alone or with other pain medications

Adjuvant Medications

Describe products and practices that are used in addition to mainstream medical practices

Natural products: include herbals and botanicals, as well as vitamins and minerals

Mind and body practices: include acupuncture, massage therapy, meditation, movement therapies, relaxation techniques, spinal manipulation, tai chi, healing touch, and yoga

Complementary and Alternative Medicine (CAM)

Heat and cold

Visualization or imagery

Progressive relaxation

Distraction

Exercise

Peripheral nerve

Music therapy

Hypnosis

Education

Other Therapies

Patients vary greatly in their medication requirements, choices of nonpharmacologic interventions, and prior pain experiences.

Patients and families should be involved in the plan.

Individualized Planning