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Is there such a thing as geriatric pain?
119
Pain, 46(1991) 119-121 0 1991 Elsevier Science Publishers B.V. 0304-3959/9t/$O3.50
PAIN 01834
Guest Editorial Is there such a thing as geriatric pain? Pamela S. Melding P~chi~tr~t
for theElders, ~~~rt~Shore Hospital, Auckland 9 (New Zealand)
(Received 5 December 1990, revision received and accepted 15 January 1991)
Each year over 4000 papers (Medline data) are published on pain, but less than 1% of these focus on pain experience or syndromes in the elderly person. Why are there so few? Are pain problems in the elderly too difficult to study or is it due to lack of interest? Perhaps we should ask if there is even such a thing as geriatric pain? Do we know if advancing age changes the nature of pain? Is pain in the elderly any different to that already described in the adult literature? Perhaps we should then ask, is the literature truly representative of all adult age groups? If we decide that indeed pain is an important issue for the elderly, then the next question we must ask is, what do we need to do about it? It would seem important to at least begin to contemplate these questions. As we enter the 21st century, an increasing number of old people in the populations or urbanised cultures is predicted, both in absohrte numbers as the general population grows and in percentage of population terms. Better health standards already mean that a person reaching sixty-five can expect to reach his/her eighties, By the year 2030, the ‘baby boom’ generation will have reached old age and the number of elderly in the population could reach 20% [8]. As the elderly population grows in number it is probable that we wil1 also see an increase in the number of elderly folk presenting with problems of chronic pain. Epidemiological data on pain in the elderly are lacking and the studies that exist often come to quite different conclusions. For example, Crook et al. ISI showed that the age-specific morbidity rate for persistent pain increases with age. Other studies concur [1.5,171 and give prevalance figures of 7380% for pain complaints in the elderly. Wood and Badley f181 also report that in a general population, at least 25% of the people who have serious impairment due to low back pain are over sixty-five. In contrast,
Correspondence to: Dr. P.S. Melding, Psychiatrist for the Elderly, North Shore Hospital, Auckland 9, New Zealand.
the large Nuprin epidemiological survey noted an agerelated reduction in the prevalence of chronic pain at all sites other than joints [16]. Considering that this finding is contrary to what most clinicians working with elderly might expect, critical examination of this finding is perhaps warranted. Perhaps it is not the sensation of pain itself that declines with ageing, it might be that the elderly have less inclination to complain about pain. If, indeed it is true that pain decreases with advancing age, then surely attention needs to be directed towards discovering why this should be so, as it could be important to our understanding of nociception. Clinical experience tells us that old people have lots of pain. They are prone to many painful diseases such as osteoporosis, osteomalacia, osteoarthritis, rheumatoid arthritis and Paget’s disease, all of which can lead to collapsed vertebrae, bone radicular and chronic back pain. Cervical spondylosis often leads to chronic persistent occipital headache as well as neck discomfort. Severe, dysaesthetic intractable pain not uncommonly fohows stroke as infarction destroys sensory pathways and the thalamic syndrome is well described. The elderly are also prone to injury from fractured bones, and prolonged healing can lead to pain and disability, particularly if lack of active rehabilitation or disuse foilows injury 111.The elderly are more prone to vascular disease, such as intermittent claudication, sympathetic dystrophies and vascuIitis which may progress to ~putation with subsequent phantom pain. The incidence of neuropathies from diabetes mellitus, alcohol overuse and malnutrition increases with advancing age. Herpes zoster or ‘shingles’ also affects mainly elderly people. With such a multitude of problems why are our pain clinics not brimming with old people? Besides the well recognised pain syndromes which are more likely to occur with increasing age, the possibility that the biological changes of ageing may have an effect on pain pathways has received scant attention. Degeneration occurs in body organs with advancing
120
age, including the central and autonomic nervous systems with loss of quality of nerve cell processes [2]. But how does degeneration of, diminished response to. or imbalances in ageing neurotransmitter and neuroendocrine systems affect the pathophysiology and perception of pain? Do they enhance or diminish pain or do both’? Is pain similar to hearing and vision in which sensitivity declines with age? And how does cognitive impairment influence pain? These questions beg to bc answered. Ageing also brings changes in psychological and social functioning. If we look for psychosocial factors, particularly those thought to be important in the perception and perpetuation of chronic pain. WCfind that the elderly have them in abundance. Pain may be used by the elderly to justify loss of mobility and to legitimize dependence [14] and in some, particularly those in institutional care, abnormal illness behaviour may be a way to get needs for love, contact and attention met. Depressive symptoms are common and there are well established links between depression, physical illness and chronic pain [l 11. The symptoms of depression can be disabling, with chronic loss of sleep, appetite, weight loss, reduction in motivation and self cares all of which can enhance sensitivity to pain and discomfort ]tOf. The elderly often have a contracted range of coping strategies and are less resilient than younger adults and they quickly become demoralised with loss of confidence during illness or after injury. The elderly are also prone to major life stressors. Bereavement is a regular occurrence. Life partners are lost and so are friends, jobs, homes, health, independence and self worth. We also need to remember that mortality is not always from natural causes, as suicide in a depressed elderly person, living alone, who has a chronic painful illness is a serious risk [3]. Psychosocial and emotional ‘pain’ is not insignificant in the aged and, as outlined above, neither is the incidence of painful physical disease. But how do these aspects relate? Or do they even equate? Or do they actually summate? What is ‘geriatric’ pain? WC might know more about pain in this age group if the elderly were better represented in pain clinic clients, Crook et al. [6,7] followed up a cohort of persistent pain patients in a family practice and compared these with a cohort from a pain clinic. The incidence of retirees in the family practice was 19% but only 13% in the pain clinic cohort. Many. if not most, pain clinic studies make very little comment on age ranges in their samples, usually confining their remarks to the average age of their population which is commonly between 40 and 50 years. Those elderly who are included in pain clinic studies are likely to be the more mobile ‘young old’ (65-75). The ‘aid old’ (over 75) often do not get to pain clinics, as many are simply not even referred by their primary
practitioners. Is this due to age-related stoicism reducing complaints of pain 1171 or to ncgativc rcfcrral biases or both? When it comes to deciding trcatmeFlt options even psychiatrists do not appear to be immune from prejudicial stereotyping of their elderly patients! [9]. Should we not ask if negative attitudes arc prcventing authentic studies of pain in elderly pcoplc? For, until we have quality data, assumptions about pain in the elderly have little scientific value. So. given the potentially high incidence of biological, psychological and social morbidity factors associated with chronic pain syndromes in the elderly, why is increasing focus not applied to this age group? Could the lack of attention to the problem be a covert from ot ageism? The pain disabled elderly have traditionally been treated with medication, which can result in problems of sensitivity and unacceptable side effects [4]. and they arc not often offered rehabilitation programmes. Why ever not’? Recently, ~iddaugh et al, [ 131and Sorkin et al. [IS] presented data which suggest that older people can indeed benefit from multidisciplinary pain rehabilitation programmes. Don’t WCriced more challenges to nihilistic attitudes such as ‘Dope and Hope the problem will go away‘?’ Because it won’t. It could get worse. As the p~)pulation ages and years of retirement lengthen chronic pain problems are going to blight the lives of many elderly. Isn’t it time to think seriously about how we can best help them?
References I Bortz, 69
W.M.,
The
disuse syndrome,
West.
J. Med.,
111 (IYXJ)
l-604.
Bowen,
D.M.
and
Davison,
A.N..
Biochemical
normal ageing brain and in dementia. Advances burgh,
in Geriatric
Medicine
1. Churchill
tn the Recent
Livingstone.
Edin-
IY7X.
Catell, H.R.,
Elderly Suicide in London: an Analysis of Coroner’s
Inquests. Jnt. J. Geriat.
Psychiat., 3 (lYX8)
Cohen, J.L., Pharmacokinetic
Suppi.SA Crook,
changes
In: B. lsaacs (Ed.),
251-X1.
changes in ageing.
80
(198hJ 31-X
J., Rideout.
E. and Browne,
c~)mpiaints in a general Crook, J.. Tunks, cal comparison
population,
E., Rideout,
prevalence
E. and Browne.
of persistent
clinic and in the community.
G.. The
of pain
Pain, 18 t 1984) 299-314.
pain sufferers Arch.
G., Epidemioiogi-
in a speciality
Phys. Med.
Rehah..
pain
67 (1986)
351-455. Crook,
J., Weir,
R. and Tunks,
survey of persistent
E., An epidemiological
pain sufferers
toliow-up
in a group family practice
and
speciality pain clinic, Pain, 36 (1989) 49-61. Eastwood,
R. and Corbin.
in old age. In: T. Arie atrics, Vol.
I, Churchill
Ford, C.V.
and Sbordone,
elderly patients, 10 Gurland.
D.E.
Edinburgh.
137 (1980)
Jl.R., Thomas.
10X5, pp. 17-32.
571-575. C’.. Depression
relations
Psychiat., 3 (1988)
G.J.. Kelman.
disorders
in Psychogeri.
of psychiatrists toward
and Berkman,
reciprocal
of mental
Advances
R.J., Attitudes
Am. J. Psychiat.,
B.J.. Wilder,
age. Int. .I. Geriat. Kennedy.
Recent
Livingstone,
L~isabjlity in the elderly:
II
S., Epidemiology
(Ed.),
and
and changes with
163-170. C’.. Wisnicwski.
W.. Met/.
121 15 Sorkin~ B,A,, Rudy, TL, ~an~~n~ R,B,, Turk, DLandStieg,
differences appear R,L1 Chronic pain in old and young patients:
12 Levcnthal, E.A. and Prohaska. T.R., Age, symptom interpretation and health behavior, J. Am. Geriat. Sot., 34 (1986) 185-191. 13 Middaugh, S.J., Levin, R.B., Kee. W.G., Barchiesi, F.D. and Roberts, J.M.. Chronic pain: its treatment in geriatric and younger patients, Arch. Phys. Med. Rehab., 69 (1988) 102l-1026. 14 McIntosh, LB., Psychological aspects influence the threshold of pain, Geriat. Med., 20 (19YO)37-41.
16 Sternbach, R.A.. Survey of pajn in the United States: the Nuprin Pain Report, J. Clin. Pain. 2 (1986) 49-54. I7 Thomas, M.R. and Roy, R., Age and pain: a comparative study of the younger and older elderly, J. Pam Manage., I (198s) 174-179. 18 Wood, P.H.N. and Radley, EM., Back pain in the community, Clin. Rheum. Dis., 6 (1980) 3-16.
Pain, 46(1991) 119-121 0 1991 Elsevier Science Publishers B.V. 0304-3959/9t/$O3.50
PAIN 01834
Guest Editorial Is there such a thing as geriatric pain? Pamela S. Melding P~chi~tr~t
for theElders, ~~~rt~Shore Hospital, Auckland 9 (New Zealand)
(Received 5 December 1990, revision received and accepted 15 January 1991)
Each year over 4000 papers (Medline data) are published on pain, but less than 1% of these focus on pain experience or syndromes in the elderly person. Why are there so few? Are pain problems in the elderly too difficult to study or is it due to lack of interest? Perhaps we should ask if there is even such a thing as geriatric pain? Do we know if advancing age changes the nature of pain? Is pain in the elderly any different to that already described in the adult literature? Perhaps we should then ask, is the literature truly representative of all adult age groups? If we decide that indeed pain is an important issue for the elderly, then the next question we must ask is, what do we need to do about it? It would seem important to at least begin to contemplate these questions. As we enter the 21st century, an increasing number of old people in the populations or urbanised cultures is predicted, both in absohrte numbers as the general population grows and in percentage of population terms. Better health standards already mean that a person reaching sixty-five can expect to reach his/her eighties, By the year 2030, the ‘baby boom’ generation will have reached old age and the number of elderly in the population could reach 20% [8]. As the elderly population grows in number it is probable that we wil1 also see an increase in the number of elderly folk presenting with problems of chronic pain. Epidemiological data on pain in the elderly are lacking and the studies that exist often come to quite different conclusions. For example, Crook et al. ISI showed that the age-specific morbidity rate for persistent pain increases with age. Other studies concur [1.5,171 and give prevalance figures of 7380% for pain complaints in the elderly. Wood and Badley f181 also report that in a general population, at least 25% of the people who have serious impairment due to low back pain are over sixty-five. In contrast,
Correspondence to: Dr. P.S. Melding, Psychiatrist for the Elderly, North Shore Hospital, Auckland 9, New Zealand.
the large Nuprin epidemiological survey noted an agerelated reduction in the prevalence of chronic pain at all sites other than joints [16]. Considering that this finding is contrary to what most clinicians working with elderly might expect, critical examination of this finding is perhaps warranted. Perhaps it is not the sensation of pain itself that declines with ageing, it might be that the elderly have less inclination to complain about pain. If, indeed it is true that pain decreases with advancing age, then surely attention needs to be directed towards discovering why this should be so, as it could be important to our understanding of nociception. Clinical experience tells us that old people have lots of pain. They are prone to many painful diseases such as osteoporosis, osteomalacia, osteoarthritis, rheumatoid arthritis and Paget’s disease, all of which can lead to collapsed vertebrae, bone radicular and chronic back pain. Cervical spondylosis often leads to chronic persistent occipital headache as well as neck discomfort. Severe, dysaesthetic intractable pain not uncommonly fohows stroke as infarction destroys sensory pathways and the thalamic syndrome is well described. The elderly are also prone to injury from fractured bones, and prolonged healing can lead to pain and disability, particularly if lack of active rehabilitation or disuse foilows injury 111.The elderly are more prone to vascular disease, such as intermittent claudication, sympathetic dystrophies and vascuIitis which may progress to ~putation with subsequent phantom pain. The incidence of neuropathies from diabetes mellitus, alcohol overuse and malnutrition increases with advancing age. Herpes zoster or ‘shingles’ also affects mainly elderly people. With such a multitude of problems why are our pain clinics not brimming with old people? Besides the well recognised pain syndromes which are more likely to occur with increasing age, the possibility that the biological changes of ageing may have an effect on pain pathways has received scant attention. Degeneration occurs in body organs with advancing
120
age, including the central and autonomic nervous systems with loss of quality of nerve cell processes [2]. But how does degeneration of, diminished response to. or imbalances in ageing neurotransmitter and neuroendocrine systems affect the pathophysiology and perception of pain? Do they enhance or diminish pain or do both’? Is pain similar to hearing and vision in which sensitivity declines with age? And how does cognitive impairment influence pain? These questions beg to bc answered. Ageing also brings changes in psychological and social functioning. If we look for psychosocial factors, particularly those thought to be important in the perception and perpetuation of chronic pain. WCfind that the elderly have them in abundance. Pain may be used by the elderly to justify loss of mobility and to legitimize dependence [14] and in some, particularly those in institutional care, abnormal illness behaviour may be a way to get needs for love, contact and attention met. Depressive symptoms are common and there are well established links between depression, physical illness and chronic pain [l 11. The symptoms of depression can be disabling, with chronic loss of sleep, appetite, weight loss, reduction in motivation and self cares all of which can enhance sensitivity to pain and discomfort ]tOf. The elderly often have a contracted range of coping strategies and are less resilient than younger adults and they quickly become demoralised with loss of confidence during illness or after injury. The elderly are also prone to major life stressors. Bereavement is a regular occurrence. Life partners are lost and so are friends, jobs, homes, health, independence and self worth. We also need to remember that mortality is not always from natural causes, as suicide in a depressed elderly person, living alone, who has a chronic painful illness is a serious risk [3]. Psychosocial and emotional ‘pain’ is not insignificant in the aged and, as outlined above, neither is the incidence of painful physical disease. But how do these aspects relate? Or do they even equate? Or do they actually summate? What is ‘geriatric’ pain? WC might know more about pain in this age group if the elderly were better represented in pain clinic clients, Crook et al. [6,7] followed up a cohort of persistent pain patients in a family practice and compared these with a cohort from a pain clinic. The incidence of retirees in the family practice was 19% but only 13% in the pain clinic cohort. Many. if not most, pain clinic studies make very little comment on age ranges in their samples, usually confining their remarks to the average age of their population which is commonly between 40 and 50 years. Those elderly who are included in pain clinic studies are likely to be the more mobile ‘young old’ (65-75). The ‘aid old’ (over 75) often do not get to pain clinics, as many are simply not even referred by their primary
practitioners. Is this due to age-related stoicism reducing complaints of pain 1171 or to ncgativc rcfcrral biases or both? When it comes to deciding trcatmeFlt options even psychiatrists do not appear to be immune from prejudicial stereotyping of their elderly patients! [9]. Should we not ask if negative attitudes arc prcventing authentic studies of pain in elderly pcoplc? For, until we have quality data, assumptions about pain in the elderly have little scientific value. So. given the potentially high incidence of biological, psychological and social morbidity factors associated with chronic pain syndromes in the elderly, why is increasing focus not applied to this age group? Could the lack of attention to the problem be a covert from ot ageism? The pain disabled elderly have traditionally been treated with medication, which can result in problems of sensitivity and unacceptable side effects [4]. and they arc not often offered rehabilitation programmes. Why ever not’? Recently, ~iddaugh et al, [ 131and Sorkin et al. [IS] presented data which suggest that older people can indeed benefit from multidisciplinary pain rehabilitation programmes. Don’t WCriced more challenges to nihilistic attitudes such as ‘Dope and Hope the problem will go away‘?’ Because it won’t. It could get worse. As the p~)pulation ages and years of retirement lengthen chronic pain problems are going to blight the lives of many elderly. Isn’t it time to think seriously about how we can best help them?
References I Bortz, 69
W.M.,
The
disuse syndrome,
West.
J. Med.,
111 (IYXJ)
l-604.
Bowen,
D.M.
and
Davison,
A.N..
Biochemical
normal ageing brain and in dementia. Advances burgh,
in Geriatric
Medicine
1. Churchill
tn the Recent
Livingstone.
Edin-
IY7X.
Catell, H.R.,
Elderly Suicide in London: an Analysis of Coroner’s
Inquests. Jnt. J. Geriat.
Psychiat., 3 (lYX8)
Cohen, J.L., Pharmacokinetic
Suppi.SA Crook,
changes
In: B. lsaacs (Ed.),
251-X1.
changes in ageing.
80
(198hJ 31-X
J., Rideout.
E. and Browne,
c~)mpiaints in a general Crook, J.. Tunks, cal comparison
population,
E., Rideout,
prevalence
E. and Browne.
of persistent
clinic and in the community.
G.. The
of pain
Pain, 18 t 1984) 299-314.
pain sufferers Arch.
G., Epidemioiogi-
in a speciality
Phys. Med.
Rehah..
pain
67 (1986)
351-455. Crook,
J., Weir,
R. and Tunks,
survey of persistent
E., An epidemiological
pain sufferers
toliow-up
in a group family practice
and
speciality pain clinic, Pain, 36 (1989) 49-61. Eastwood,
R. and Corbin.
in old age. In: T. Arie atrics, Vol.
I, Churchill
Ford, C.V.
and Sbordone,
elderly patients, 10 Gurland.
D.E.
Edinburgh.
137 (1980)
Jl.R., Thomas.
10X5, pp. 17-32.
571-575. C’.. Depression
relations
Psychiat., 3 (1988)
G.J.. Kelman.
disorders
in Psychogeri.
of psychiatrists toward
and Berkman,
reciprocal
of mental
Advances
R.J., Attitudes
Am. J. Psychiat.,
B.J.. Wilder,
age. Int. .I. Geriat. Kennedy.
Recent
Livingstone,
L~isabjlity in the elderly:
II
S., Epidemiology
(Ed.),
and
and changes with
163-170. C’.. Wisnicwski.
W.. Met/.
121 15 Sorkin~ B,A,, Rudy, TL, ~an~~n~ R,B,, Turk, DLandStieg,
differences appear R,L1 Chronic pain in old and young patients:
12 Levcnthal, E.A. and Prohaska. T.R., Age, symptom interpretation and health behavior, J. Am. Geriat. Sot., 34 (1986) 185-191. 13 Middaugh, S.J., Levin, R.B., Kee. W.G., Barchiesi, F.D. and Roberts, J.M.. Chronic pain: its treatment in geriatric and younger patients, Arch. Phys. Med. Rehab., 69 (1988) 102l-1026. 14 McIntosh, LB., Psychological aspects influence the threshold of pain, Geriat. Med., 20 (19YO)37-41.
16 Sternbach, R.A.. Survey of pajn in the United States: the Nuprin Pain Report, J. Clin. Pain. 2 (1986) 49-54. I7 Thomas, M.R. and Roy, R., Age and pain: a comparative study of the younger and older elderly, J. Pam Manage., I (198s) 174-179. 18 Wood, P.H.N. and Radley, EM., Back pain in the community, Clin. Rheum. Dis., 6 (1980) 3-16.