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Pain management in older adults
MEDICINE IN OLDER ADULTS
Pain management in older adults
Key points C
We are facing a significant increase in the ageing population, which will be accompanied by a significant number of older adults with communication difficulties such as dementia
C
Pain is a common problem in the ageing population and increases significantly in those living in nursing homes
C
Pain management is generally poor, with poor pain assessment, underprescribing and underadministration
C
There is recommended guidance on pain assessment for this group, as well as behavioural scales that can be used when there are communication difficulties
C
Numerical rating scales and verbal descriptors are appropriate for older adults, but the approach may need to be varied
C
The Abbey, PAINAD and DOLOPLUS scales are recommended where the adult has cognitive impairment
C
Most research around management has been conducted with younger adults and simply translated to older adults
C
Paracetamol is the drug of choice for pain management. Opioids can be used, but the approach should be to ‘start low, go slow’
C
Some invasive treatments for chronic pain are effective, but more research is needed.
Patricia Schofield
Abstract We are seeing a significant increase in the older population far outweighing that in younger cohorts, and this is set to dramatically increase by 2050. With increasing age comes an increased risk of co-morbidities and consequently a likelihood of pain. Pain is a common problem for older adults; many reports suggest that the incidence is around 50% in older adults living in the community, increasing to 80% among the nursing home population. Dealing with pain in this population is complex and becomes even more challenging when cognitive impairment exists. This article highlights the challenges, proposes strategies for the assessment and management of pain in the older population and makes recommendations for future research in this area.
Keywords Ageing; assessment; management; pain
Introduction Our population is ageing, with a significant increase in the number of older adults anticipated over the next 25 years, and a decrease in younger counterparts. So we are expecting to see the ratio of older adults increase to that of younger adults. With this will come a higher number of older adults with cognitive impairments. There are already around 850,000 older adults with dementia in the UK. Therefore an ageing population coupled with an increase in co-morbidities and potential communication difficulties is likely to present future challenges to pain assessment and management. Historically, evidence has suggested that pain is a common problem for older people, with chronic persistent pain affecting at least 50% of community-dwelling older adults, the figure increasing to 80% among those living in care homes. More recent systematic reviews of the literature confirm that this is still the
case.1 As the percentage of our ageing population increases over time (Figure 1), greater demands will be placed on healthcare professionals and informal carers to cope with the problems associated with old age, especially pain assessment and management. Pain management in older adults is generally poor. The rate of admission to hospital for patients >65 years of age is three times higher than for younger people, and there is evidence that professionals tend to underestimate pain needs, underprescribe and undermedicate. This may in part relate to fears and misconceptions among prescribers regarding pre-existing co-morbidities and the effects of prescribed medicines. Such fears and anxieties are not totally unfounded as older adults tend to have co-morbidities, with concurrent medications prescribed. They are also more likely to have diminished functional status and physiological reserve, as well as age-related pharmacodynamic and pharmacokinetic changes. Cognitive impairment can prevent or complicate adequate pain assessment. In all care settings, healthcare professionals should be aware of pain assessment tools that can be used with older adults e both those who can communicate their pain and those unable to do so as a result of cognitive impairment. It is frequently assumed that chronic pain is simply a part of getting older and something the individual must learn to live
Patricia Schofield RGN PhD PGDipEd DipN is Professor of Nursing, Deputy Dean Research and Income Generation, Anglia Ruskin University, UK. She has completed several postdoctoral projects around pain management in older people, including talking to them about their pain experiences, with funding from the MRC, EU and ESRC. She recently published the national guidelines for the management of pain in older adults and updated the national pain assessment guidelines for older adults, both after a working party of the British Geriatrics Society and British Pain Society. She is involved in a number of other studies including the pain assessment application evaluation (iPhone APP) with paramedics, a positive ageing peer education project and an end-of-life and dementia project. She has written over 150 peer-reviewed publications and a number of books in this field and spoken at many national and international conferences. Competing interests: none declared.
MEDICINE --:-
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Schofield P, Pain management in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.005
MEDICINE IN OLDER ADULTS
with. However, there is a growing body of research into chronic pain management for older adults, and increasing awareness that self-management of chronic pain is a viable strategy for this population regardless of level of cognitive ability.1
Many pain intensity scales are used in practice with the adult population in general, but not all are appropriate for the older population. In 2007, a UK national pain assessment guideline for specific use in older people was published.3 This guidance was updated in 2015. The best evidence to date recommends numerical rating scales (0e10) and verbal rating scales (none, mild, moderate, severe) (Figure 2, Table 1). Both types of scale can be used in the presence of mild to moderate cognitive impairment, but consideration must be given to the visual presentation to ensure that the scales are in large enough print to be seen. It is also important to be flexible: if one scale does not work, carers should change their approach and adopt an alternative. Similarly, the choice of words should be flexible and modified accordingly. For example, ‘pain’ may need to be replaced with ‘soreness’ or ‘hurting’, and the question may need to be repeated. The least effective scale for use with the older population is the visual analogue scale. The presence and intensity of pain are not the only factors that should be assessed. Pain is a multidimensional experience, and assessment should also consider the onset, time-course, radiation, aggravating/relieving factors, information on current and previous management, including medications and complementary therapies, impact of the symptom on physical function or quality of life, and the patient’s beliefs, understanding and expectations related to the pain. For older adults, a number of other issues may be as important as, if not more important than, the pain itself. These include, quality of life, depression, mobility, social isolation and independence. The patient is the main source of information in the assessment process, but it is also important that carers or family members are involved, particularly if the patient is unable to communicate.
Pain assessment
Behavioural pain assessment
The American Pain Society has stated that pain is the ‘fifth vital sign’,2 emphasizing the importance of routine and systematic assessment and monitoring similar to that undertaken for respiration, pulse and blood pressure; it is therefore not an assessment to be avoided because it may be challenging. Pain assessment is now considered to be the fundamental first step in the complete pain management process, and many healthcare professionals carry out effective pain assessment in most areas of practice as a routine part of care. The process of assessing pain in older adults can be complicated by the presence of not only cognitive impairment, but also visual or hearing problems and other communication difficulties, for example dysphasia caused by the common co-morbidity of cerebrovascular disease. Pain intensity scales can be used for older adults with mild or moderate levels of cognitive impairment. If possible, the patient’s own descriptions should be used, and if the person denies the presence of pain when asked directly, it can be useful to follow up with questions around ‘aching’ or ‘soreness’. It has been demonstrated that many older adults do not like to complain about pain, perhaps because of increased levels of stoicism; this can be worse among the residents of care homes, who may not wish to be perceived as a ‘problem’ to carers or staff.
Observation is a vital tool when assessing the existence or intensity of pain, particularly in patients who have communication problems, such as cognitive impairments or visual and hearing problems. Commonly cited indicators include facial expressions and body movement (guarding to protect against pain) and physical indicators such as pallor, tachycardia and hypertension. Over the last two decades, a number of pain scales have been designed to measure behaviours associated with pain. At least seven currently exist4 and are consistent in listing the following observable or recordable phenomena associated with pain: physiological observations (e.g. changes in respiration or pulse) facial expressions (e.g. grimacing) body movements (e.g. uncharacteristic restlessness) verbalizations (not clearly indicating the presence of pain) changes in interpersonal interactions (e.g. uncharacteristic aggression towards carers) changes in activity or routines (e.g. wishing to stay longer in bed) changes in mental status (e.g. depression, confusion). The tools have so far been evaluated only in single clinical settings, and it is difficult to recommend one particular tool as being more reliable and valid.
Figure 1
MEDICINE --:-
2
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Schofield P, Pain management in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.005
MEDICINE IN OLDER ADULTS
Figure 2
Pain assessment scales
Since the publication of the UK Assessment Guidance in 2007,3 further research has been undertaken, using the Doloplus, Pain Assessment in Advanced Dementia (PAINAD) and Noncommunicative Patient’s Pain Assessment Instrument (NOPPAIN) scales, and there have been moves to develop an internationally recognized scale. Furthermore, a ‘sister scale’ to Doloplus e Algoplus e has been developed for measuring acute pain in adults with cognitive impairment. This scale only takes 1 minute to complete, thereby lending itself to busy acute care settings. Although the new recommendations suggest that there is more evidence to underpin the PAINAD scale as opposed to the
MEDICINE --:-
Verbal rating scale None Mild Moderate Severe Numerical rating scale
Table 1
3
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Schofield P, Pain management in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.005
MEDICINE IN OLDER ADULTS
Analgesics for use with older adults (the WHO ‘three-step analgesic ladder’ is a good way to titrate people into appropriate drug regimens and this can fit well with pain assessment scales, therefore: none, mild, moderate and severe) Drug
Adverse effects
Dose
Paracetamol should be considered as first-line treatment in older people for the management of both acute and persistent pain because of its demonstrated efficacy and good safety profile Non-selective NSAIDs and selective COX-2 inhibitors should be used in older people only after other safer treatments have not provided sufficient pain relief
There are few relative cautions and absolute contraindications to prescribing paracetamol
It is important that the maximum daily dose (4 g/24 hour) is not exceeded
For older people, an NSAID or selective COX-2 inhibitor should be co-prescribed with a proton pump inhibitor, choosing the one with the lowest acquisition cost All older people taking NSAIDs or COX-2 inhibitors should be routinely monitored for gastrointestinal, renal and cardiovascular adverse effects, and drugedrug and drugedisease interactions Opioid adverse effects (including nausea and vomiting) should be anticipated and suitable prophylaxis considered Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people taking opioid therapy Regular patient review is required to assess the therapeutic benefit and monitor adverse effects
The lowest dose should be used for the shortest duration
Opioids have demonstrated efficacy in the short term for both cancer and non-cancer pain, but long-term data are lacking. All patients with moderate and severe pain should be considered for opioid therapy, particularly if the pain is causing functional impairment or reducing quality of life Patients with continuous pain should be treated with modified-release oral or transdermal opioid formulations aimed at providing relatively constant plasma concentrations Antiepileptic drugs have demonstrated efficacy in several types of neuropathic pain
Tricyclic antidepressants have demonstrated efficacy in several types of neuropathic pain
Adverse effects and the need for blood monitoring limit the use of older antiepileptic drugs in older people Dose adjustment of gabapentin and pregabalin is required in renal impairment Regular patient review is required to assess the therapeutic benefit and monitor adverse effects Adverse effects and contraindications limit the use of tricyclic antidepressants in older people Duloxetine has been shown to be effective for the treatment of neuropathic pain, and some studies suggest efficacy for non-neuropathic pain such as osteoarthritis and low back pain Other antidepressants (e.g. SSRIs) have very limited evidence of analgesic efficacy and should not be used as analgesics
As there is marked variability in individual response to opioids, treatment must be individualized and carefully monitored for efficacy and tolerability
The lowest dose should be initiated and the dose increased slowly as tolerated Regular patient review is required to assess the therapeutic benefit and monitor adverse effects
COX-2, cyclooxygenase-2; SSRI, selective serotonin reuptake inhibitor. Adapted from Knaggs, R, Pharmacological approaches to management. In: Schofield et al. (2012).5
Table 2
MEDICINE --:-
4
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Schofield P, Pain management in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.005
MEDICINE IN OLDER ADULTS
Abbey scale, it is important to consider what works in practice. Many clinical areas are successfully using the Abbey scale in practice, and we would not encourage a change e the suggestion is simply that PAINAD has more evidence to support it, but Abbey is clinically effective. We have recently conducted research into the use of the pain assessment iPhone application with paramedics in the South East Coast ambulance service (awaiting publication). This tool has incorporated the Abbey scale and has been very effective in helping paramedics to identify pain in adults with dementia.
development of randomized controlled trials, inform the education of medical and allied health professionals and influence policy, as has been seen with the British National Health Service Cancer Plan. The reviews of the literature carried out to prepare for this article have demonstrated that although there has been some research into pain and the older population, particularly around pain assessment, there is still a need to look more closely at the work related to interventions and ageing. It is interesting to note that we are now seeing a proliferation of papers related to pain and ageing, and the topic is moving up the agenda at conferences. Whereas the topic previously always came at the end of conferences, it is now nearing the top and generally being oversubscribed. This is either a good sign that people are becoming more interested in the topic and recognizing its importance, or they are also facing the prospect of ageing! A
Management of pain The UK national pain management guidelines for older people were published in 2014.5 Key points included the use of drugs such as paracetamol as the first line of treatment for acute or persistent pain, emphasizing that alternatives, including opioids, could be used if necessary on a ‘start low, go slow’ basis. Nonsteroidal anti-inflammatory drugs (NSAIDs) have a place, but only for short-term use (Table 2). There are also alternative approaches such as psychological therapies and self-management strategies. Finally, there are adjuvant treatments such as transcutaneous electrical nerve stimulation and acupuncture, which have a relatively small body of evidence supporting their use. We have concluded that there is limited evidence regarding invasive modalities. Interestingly, many of the recommendations are based on studies carried out with adults in general and simply translated to the older population, an issue that needs to be addressed. More research looking at the impact of pharmacological and invasive interventions specifically with the older population needs to be carried out. There is often discussion on the effectiveness of clinical guidelines in practice. Guidelines, although challenging to implement, can reduce variation in practice and also inform the
MEDICINE --:-
KEY REFERENCES 1 Schofield P, Clarke A, Jones D, Martin D, McNamee P, Smith B. Chronic pain in later life: a review of current issues and challenges. Aging Health 2011; 7: 551e6. 2 Joint Commission on Accreditation of Healthcare Organizations. Pain assessment and management standards. 2002. Available from: https://www.jointcommission.org/joint_commission_ statement_on_pain_management/. 3 British Pain Society/British Geriatrics Society. The assessment of pain in older adults e national guidelines. 2007. Available from: https://www.guidelines.co.uk/rps-bgs-bps/pain-management. 4 Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc 2003; 4: 9e15. 5 Schofield PA. The management of pain in older adults e guidelines for practice. London: British Geriatrics Society/British Pain Society, 2012.
5
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Schofield P, Pain management in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.005
Pain management in older adults
Key points C
We are facing a significant increase in the ageing population, which will be accompanied by a significant number of older adults with communication difficulties such as dementia
C
Pain is a common problem in the ageing population and increases significantly in those living in nursing homes
C
Pain management is generally poor, with poor pain assessment, underprescribing and underadministration
C
There is recommended guidance on pain assessment for this group, as well as behavioural scales that can be used when there are communication difficulties
C
Numerical rating scales and verbal descriptors are appropriate for older adults, but the approach may need to be varied
C
The Abbey, PAINAD and DOLOPLUS scales are recommended where the adult has cognitive impairment
C
Most research around management has been conducted with younger adults and simply translated to older adults
C
Paracetamol is the drug of choice for pain management. Opioids can be used, but the approach should be to ‘start low, go slow’
C
Some invasive treatments for chronic pain are effective, but more research is needed.
Patricia Schofield
Abstract We are seeing a significant increase in the older population far outweighing that in younger cohorts, and this is set to dramatically increase by 2050. With increasing age comes an increased risk of co-morbidities and consequently a likelihood of pain. Pain is a common problem for older adults; many reports suggest that the incidence is around 50% in older adults living in the community, increasing to 80% among the nursing home population. Dealing with pain in this population is complex and becomes even more challenging when cognitive impairment exists. This article highlights the challenges, proposes strategies for the assessment and management of pain in the older population and makes recommendations for future research in this area.
Keywords Ageing; assessment; management; pain
Introduction Our population is ageing, with a significant increase in the number of older adults anticipated over the next 25 years, and a decrease in younger counterparts. So we are expecting to see the ratio of older adults increase to that of younger adults. With this will come a higher number of older adults with cognitive impairments. There are already around 850,000 older adults with dementia in the UK. Therefore an ageing population coupled with an increase in co-morbidities and potential communication difficulties is likely to present future challenges to pain assessment and management. Historically, evidence has suggested that pain is a common problem for older people, with chronic persistent pain affecting at least 50% of community-dwelling older adults, the figure increasing to 80% among those living in care homes. More recent systematic reviews of the literature confirm that this is still the
case.1 As the percentage of our ageing population increases over time (Figure 1), greater demands will be placed on healthcare professionals and informal carers to cope with the problems associated with old age, especially pain assessment and management. Pain management in older adults is generally poor. The rate of admission to hospital for patients >65 years of age is three times higher than for younger people, and there is evidence that professionals tend to underestimate pain needs, underprescribe and undermedicate. This may in part relate to fears and misconceptions among prescribers regarding pre-existing co-morbidities and the effects of prescribed medicines. Such fears and anxieties are not totally unfounded as older adults tend to have co-morbidities, with concurrent medications prescribed. They are also more likely to have diminished functional status and physiological reserve, as well as age-related pharmacodynamic and pharmacokinetic changes. Cognitive impairment can prevent or complicate adequate pain assessment. In all care settings, healthcare professionals should be aware of pain assessment tools that can be used with older adults e both those who can communicate their pain and those unable to do so as a result of cognitive impairment. It is frequently assumed that chronic pain is simply a part of getting older and something the individual must learn to live
Patricia Schofield RGN PhD PGDipEd DipN is Professor of Nursing, Deputy Dean Research and Income Generation, Anglia Ruskin University, UK. She has completed several postdoctoral projects around pain management in older people, including talking to them about their pain experiences, with funding from the MRC, EU and ESRC. She recently published the national guidelines for the management of pain in older adults and updated the national pain assessment guidelines for older adults, both after a working party of the British Geriatrics Society and British Pain Society. She is involved in a number of other studies including the pain assessment application evaluation (iPhone APP) with paramedics, a positive ageing peer education project and an end-of-life and dementia project. She has written over 150 peer-reviewed publications and a number of books in this field and spoken at many national and international conferences. Competing interests: none declared.
MEDICINE --:-
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Schofield P, Pain management in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.005
MEDICINE IN OLDER ADULTS
with. However, there is a growing body of research into chronic pain management for older adults, and increasing awareness that self-management of chronic pain is a viable strategy for this population regardless of level of cognitive ability.1
Many pain intensity scales are used in practice with the adult population in general, but not all are appropriate for the older population. In 2007, a UK national pain assessment guideline for specific use in older people was published.3 This guidance was updated in 2015. The best evidence to date recommends numerical rating scales (0e10) and verbal rating scales (none, mild, moderate, severe) (Figure 2, Table 1). Both types of scale can be used in the presence of mild to moderate cognitive impairment, but consideration must be given to the visual presentation to ensure that the scales are in large enough print to be seen. It is also important to be flexible: if one scale does not work, carers should change their approach and adopt an alternative. Similarly, the choice of words should be flexible and modified accordingly. For example, ‘pain’ may need to be replaced with ‘soreness’ or ‘hurting’, and the question may need to be repeated. The least effective scale for use with the older population is the visual analogue scale. The presence and intensity of pain are not the only factors that should be assessed. Pain is a multidimensional experience, and assessment should also consider the onset, time-course, radiation, aggravating/relieving factors, information on current and previous management, including medications and complementary therapies, impact of the symptom on physical function or quality of life, and the patient’s beliefs, understanding and expectations related to the pain. For older adults, a number of other issues may be as important as, if not more important than, the pain itself. These include, quality of life, depression, mobility, social isolation and independence. The patient is the main source of information in the assessment process, but it is also important that carers or family members are involved, particularly if the patient is unable to communicate.
Pain assessment
Behavioural pain assessment
The American Pain Society has stated that pain is the ‘fifth vital sign’,2 emphasizing the importance of routine and systematic assessment and monitoring similar to that undertaken for respiration, pulse and blood pressure; it is therefore not an assessment to be avoided because it may be challenging. Pain assessment is now considered to be the fundamental first step in the complete pain management process, and many healthcare professionals carry out effective pain assessment in most areas of practice as a routine part of care. The process of assessing pain in older adults can be complicated by the presence of not only cognitive impairment, but also visual or hearing problems and other communication difficulties, for example dysphasia caused by the common co-morbidity of cerebrovascular disease. Pain intensity scales can be used for older adults with mild or moderate levels of cognitive impairment. If possible, the patient’s own descriptions should be used, and if the person denies the presence of pain when asked directly, it can be useful to follow up with questions around ‘aching’ or ‘soreness’. It has been demonstrated that many older adults do not like to complain about pain, perhaps because of increased levels of stoicism; this can be worse among the residents of care homes, who may not wish to be perceived as a ‘problem’ to carers or staff.
Observation is a vital tool when assessing the existence or intensity of pain, particularly in patients who have communication problems, such as cognitive impairments or visual and hearing problems. Commonly cited indicators include facial expressions and body movement (guarding to protect against pain) and physical indicators such as pallor, tachycardia and hypertension. Over the last two decades, a number of pain scales have been designed to measure behaviours associated with pain. At least seven currently exist4 and are consistent in listing the following observable or recordable phenomena associated with pain: physiological observations (e.g. changes in respiration or pulse) facial expressions (e.g. grimacing) body movements (e.g. uncharacteristic restlessness) verbalizations (not clearly indicating the presence of pain) changes in interpersonal interactions (e.g. uncharacteristic aggression towards carers) changes in activity or routines (e.g. wishing to stay longer in bed) changes in mental status (e.g. depression, confusion). The tools have so far been evaluated only in single clinical settings, and it is difficult to recommend one particular tool as being more reliable and valid.
Figure 1
MEDICINE --:-
2
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Schofield P, Pain management in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.005
MEDICINE IN OLDER ADULTS
Figure 2
Pain assessment scales
Since the publication of the UK Assessment Guidance in 2007,3 further research has been undertaken, using the Doloplus, Pain Assessment in Advanced Dementia (PAINAD) and Noncommunicative Patient’s Pain Assessment Instrument (NOPPAIN) scales, and there have been moves to develop an internationally recognized scale. Furthermore, a ‘sister scale’ to Doloplus e Algoplus e has been developed for measuring acute pain in adults with cognitive impairment. This scale only takes 1 minute to complete, thereby lending itself to busy acute care settings. Although the new recommendations suggest that there is more evidence to underpin the PAINAD scale as opposed to the
MEDICINE --:-
Verbal rating scale None Mild Moderate Severe Numerical rating scale
Table 1
3
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Schofield P, Pain management in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.005
MEDICINE IN OLDER ADULTS
Analgesics for use with older adults (the WHO ‘three-step analgesic ladder’ is a good way to titrate people into appropriate drug regimens and this can fit well with pain assessment scales, therefore: none, mild, moderate and severe) Drug
Adverse effects
Dose
Paracetamol should be considered as first-line treatment in older people for the management of both acute and persistent pain because of its demonstrated efficacy and good safety profile Non-selective NSAIDs and selective COX-2 inhibitors should be used in older people only after other safer treatments have not provided sufficient pain relief
There are few relative cautions and absolute contraindications to prescribing paracetamol
It is important that the maximum daily dose (4 g/24 hour) is not exceeded
For older people, an NSAID or selective COX-2 inhibitor should be co-prescribed with a proton pump inhibitor, choosing the one with the lowest acquisition cost All older people taking NSAIDs or COX-2 inhibitors should be routinely monitored for gastrointestinal, renal and cardiovascular adverse effects, and drugedrug and drugedisease interactions Opioid adverse effects (including nausea and vomiting) should be anticipated and suitable prophylaxis considered Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people taking opioid therapy Regular patient review is required to assess the therapeutic benefit and monitor adverse effects
The lowest dose should be used for the shortest duration
Opioids have demonstrated efficacy in the short term for both cancer and non-cancer pain, but long-term data are lacking. All patients with moderate and severe pain should be considered for opioid therapy, particularly if the pain is causing functional impairment or reducing quality of life Patients with continuous pain should be treated with modified-release oral or transdermal opioid formulations aimed at providing relatively constant plasma concentrations Antiepileptic drugs have demonstrated efficacy in several types of neuropathic pain
Tricyclic antidepressants have demonstrated efficacy in several types of neuropathic pain
Adverse effects and the need for blood monitoring limit the use of older antiepileptic drugs in older people Dose adjustment of gabapentin and pregabalin is required in renal impairment Regular patient review is required to assess the therapeutic benefit and monitor adverse effects Adverse effects and contraindications limit the use of tricyclic antidepressants in older people Duloxetine has been shown to be effective for the treatment of neuropathic pain, and some studies suggest efficacy for non-neuropathic pain such as osteoarthritis and low back pain Other antidepressants (e.g. SSRIs) have very limited evidence of analgesic efficacy and should not be used as analgesics
As there is marked variability in individual response to opioids, treatment must be individualized and carefully monitored for efficacy and tolerability
The lowest dose should be initiated and the dose increased slowly as tolerated Regular patient review is required to assess the therapeutic benefit and monitor adverse effects
COX-2, cyclooxygenase-2; SSRI, selective serotonin reuptake inhibitor. Adapted from Knaggs, R, Pharmacological approaches to management. In: Schofield et al. (2012).5
Table 2
MEDICINE --:-
4
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Schofield P, Pain management in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.005
MEDICINE IN OLDER ADULTS
Abbey scale, it is important to consider what works in practice. Many clinical areas are successfully using the Abbey scale in practice, and we would not encourage a change e the suggestion is simply that PAINAD has more evidence to support it, but Abbey is clinically effective. We have recently conducted research into the use of the pain assessment iPhone application with paramedics in the South East Coast ambulance service (awaiting publication). This tool has incorporated the Abbey scale and has been very effective in helping paramedics to identify pain in adults with dementia.
development of randomized controlled trials, inform the education of medical and allied health professionals and influence policy, as has been seen with the British National Health Service Cancer Plan. The reviews of the literature carried out to prepare for this article have demonstrated that although there has been some research into pain and the older population, particularly around pain assessment, there is still a need to look more closely at the work related to interventions and ageing. It is interesting to note that we are now seeing a proliferation of papers related to pain and ageing, and the topic is moving up the agenda at conferences. Whereas the topic previously always came at the end of conferences, it is now nearing the top and generally being oversubscribed. This is either a good sign that people are becoming more interested in the topic and recognizing its importance, or they are also facing the prospect of ageing! A
Management of pain The UK national pain management guidelines for older people were published in 2014.5 Key points included the use of drugs such as paracetamol as the first line of treatment for acute or persistent pain, emphasizing that alternatives, including opioids, could be used if necessary on a ‘start low, go slow’ basis. Nonsteroidal anti-inflammatory drugs (NSAIDs) have a place, but only for short-term use (Table 2). There are also alternative approaches such as psychological therapies and self-management strategies. Finally, there are adjuvant treatments such as transcutaneous electrical nerve stimulation and acupuncture, which have a relatively small body of evidence supporting their use. We have concluded that there is limited evidence regarding invasive modalities. Interestingly, many of the recommendations are based on studies carried out with adults in general and simply translated to the older population, an issue that needs to be addressed. More research looking at the impact of pharmacological and invasive interventions specifically with the older population needs to be carried out. There is often discussion on the effectiveness of clinical guidelines in practice. Guidelines, although challenging to implement, can reduce variation in practice and also inform the
MEDICINE --:-
KEY REFERENCES 1 Schofield P, Clarke A, Jones D, Martin D, McNamee P, Smith B. Chronic pain in later life: a review of current issues and challenges. Aging Health 2011; 7: 551e6. 2 Joint Commission on Accreditation of Healthcare Organizations. Pain assessment and management standards. 2002. Available from: https://www.jointcommission.org/joint_commission_ statement_on_pain_management/. 3 British Pain Society/British Geriatrics Society. The assessment of pain in older adults e national guidelines. 2007. Available from: https://www.guidelines.co.uk/rps-bgs-bps/pain-management. 4 Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc 2003; 4: 9e15. 5 Schofield PA. The management of pain in older adults e guidelines for practice. London: British Geriatrics Society/British Pain Society, 2012.
5
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Schofield P, Pain management in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.005