Abstract Managing_pain_in_the_older_person

Managing pain in the older person
1
Abstract
Our population is ageing. In 1961 592 people celebrated their 100th birthdays. In 2012
14,500 celebrated and in 2035 an estimated 110,000 will be a hundred years old (ONS,
2012). There are now over 428,000 people aged 90-99. This presentation will examine the
prevalence of pain, types of pain, how ageing and long term conditions impact on pain and
treatment considerations and how to work with the older person to improve pain control,
minimise side effects and maximise concordance.
Key words: Ageing: Pain: prevalence: Types, Management
Pain is defined as
“unpleasant sensory or emotional experience associated with actual or potential tissue
damage or described in terms of such damage”(IASP, 1994)
Research indicates that around 53 percent of older adults (those aged 65 and over) have
experienced bothersome pain every month. Most (around 75 percent) had pain in multiple
sites. Women, people who were obese, had musculoskeletal conditions or symptoms of
depression reported a higher prevalence of pain. People with pain were less able than those
without pain (Patel et al, 2013). People with dementia are more likely to experience pain than
those who do not have dementia (Hunt et al, 2015). Pain is associated with impaired mobility
and balance and increases risk of falls (Patel et al, 2014). Chronic pain is common in older
people and affects the ability to move around freely, to sleep well and live a full life (Reid et al,
2015).
What types of pain does the older person experience
The older person may experience chronic pain due to osteoarthritis or muscular skeletal
conditions and pain secondary to cardiac and respiratory conditions and pain secondary to
long term complications of conditions such as diabetes such as peripheral neuropathy (Reid
et al, 2015: Hunt et al, 2015: Patel et al, 2014). The older person may experience acute pain
such as post herpetic neuralgia following an acute infection or pain following a fall and
fracture or pain secondary to a collapse of osteoporotic vertebrae (Nazarko, 2014).
Its important to differentiate between types of pain as this will guide treatment choices.
How to determine treatment options
It’s vitally important that we put the patient and his or her needs and wishes at the heart of all
treatment decisions. In order to discuss treatment options the clinician needs to determine the
cause of pain, whether the cause can be treated and whether treatment aims to support the
patient whilst the cause if treated or if the pain must be managed long-term.
National guidelines on the assessment of pain in older people are currently being reviewed.
The principles outlined are taken from current guidance (RCP, 2007).
The clinician also needs to be aware of the person’s medical and drug history, comorbidities,
allergies and intolerances.
How ageing affects treatment considerations
Age related changes cause reduced ability to absorb and excrete drugs (Wooten, 2012:
Miller, 2007: Miller, 2000: Nguyen & Goldfarb, 2012: Esposito et al, 2007: Mühlberg & Platt,
1999). Key changes are:
• Reduced gastrointestinal motility and reduced gastro-intestinal blood flow
• Changes in distribution of drugs due to decline in muscle mass and increase in fat

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• Reduced ability to metabolise drugs due to decreases in hepatic blood flow and liver
mass
• Reduced ability to excrete drugs due to decline in renal function
• Changes at molecular level that alter receptor binding and may increase or decrease
sensitivity to particular classes of drugs.
How comorbidities affect treatment options
The older person may have cardiac, renal, gastro-intestinal, respiratory or cognitive
comorbidities.
Almost 200,000 people in the UK have heart failurei. The incidence of heart failure rises
dramatically with age; around 13 percent of men and 12 percent of women aged 75 and over
have heart failure (Townsend et al, 2012). Chronic kidney disease (CKD) increases with age
1.9% of people under 64 have CKD stage 3-5, 13.5% of people aged 65-74 and 32.7% of
people aged 75 and over (Public Health England, 2014, P 4).
The older person is at increased risk of gastro-intestinal (GI) disease and each year 1% of
people aged 80 and over are hospitalised as a result of GI bleeding. The commonest causes
is peptic ulceration other causes include oesophageal varices and diverticular disease
(Yachimski & Friedman, 2008).
Around 10 percent of people aged 65 and over have asthma, this may be confused with
chronic obstructive airways disease, underdiagnosed and treated (Gillman& Douglas: 2012).
Non steroidal anti-inflammatory drugs (NSAIDs) contraindicated in cardiac failure as they can
increase oedema and worsen cardiac failure. They can lead to exacerbation of asthma and
can be nephrotoxic.
Opiates and codeine based drugs should be used with caution in older people especially
those with renal impairment.
Cognitive impairment can make it difficult for the older person to manage medication.
Dysphagia affects around 11 percent of adults living in the community (Holland et al, 2011).It
Swallowing difficulties can lead to the person being unable to take medication. In the past
soluble medications have been used however there are now concerns that these contain high
levels of sodium and increase blood pressure and non fatal strokes (George et al, 2013).
Liquid medicines can often be suitable if a person has swallowing difficulties.
Considering drug interactions
The older person’s comorbidities and general frailty may place the person at risk of falls.
These comorbidities and age related changes make the older person vulnerable to the effects
of medication that can be given relatively safely in younger people. Medication can
destabilise existing conditions or increase the risk of adverse effects such as falls) Basger et
al, 2012, Barber et al, 2009; Laaksonen et al, 2010).
Recent research shows that around half of the 20 medicines most commonly prescribed for
older people can increase the risk of falls. Medications that affect the central nervous system;
hypnotics, sedatives, analgesics and antidepressants," were of particular concern”. They
found that opioids doubled the risk of injurious fall in men and women and some non-opioid
painkillers were also linked to a 15% to 75% greater risk of fall injuries (Kuschel et al, 2014)
Medication review has been shown to significantly reduce the number of falls in people living
in care homes (Zermansky et al, 2006).The American Geriatrics Society (2012) produce the
Beers Criteria of potentially inappropriate medications for older people and this can be useful
in alerting clinicians to potential side effects and interactions.
Enabling and facilitating concordance
Adults often don’t take prescribed medication (van Dulment et al, 2007) only about 60% of
adults with long term conditions take medicines regularly enough to obtain any benefit

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(McGavock, 1997) A number of sources can alert the clinician to medication non compliance.
These include a history of not collecting repeat medicines, history from family and carer
givers, the discovery of large amounts of unused medicine in the person’s home and the
person’s own account.
When a person is not taking prescribed medication it’s important to ask why (Wright, 1993).
Medication review and minimising medication can increase the chances of the person taking
prescribed medication and minimise risk of side effects.
Working with the older person and caregivers to identify and manage side effects
Despite the cant about consumerism healthcare is at the end of the day about relationships.
It’s important to develop an open and honest relationship with the older person and his or her
caregivers so that they are aware of possible side effects. Sometimes side effects can be
managed with other drugs and at other times its best to switch drugs. If the older person and
his or her caregivers feel that they can establish a dialogue with the clinician any side effects
can be addressed.
Treating pain
Be guided by the World Health Organisation (WHO, 1998) analgesic ladder. If pain occurs,
there should be prompt oral administration of drugs in the following order: nonopioids e.g
paracetamol; then, if necessary, mild opioids (codeine); then strong opioids such as
morphine, until the patient is free of pain. T
The WHO ladder is part of an overall pain treatment method that centres on five key
principles:
1. "By Mouth": use the oral route whenever possible, even for opioids
2. “By the Clock”: For persistent pain, provide medication at regular intervals
3. “Around the clock rather than prn
4. "By the Ladder":
5. For the individual
Conclusion
It’s important to be aware that managing pain often requires a team approach and that all
interventions do not require a prescription. The older person may benefit from walking aids,
therapy, acupuncture or other non drug treatments (Abdulla et al, 2013).
Step one
•Paracetamol one gramQDS - people weighing45kgor lessmayrequire
reduceddoses
•NSAIDS- beware of cardiovascularrisks- Naproxensafest.Beware of renal,
cardiac, asthmaand othercontraindications
Step two
•Codeine - beware of renal impairement,be alerttoside effects,
constipation,nauseaandthose unabletometabolise
•Neurophaticpainoptionsgabapentinandpregabalin
•Tramadol - be aware of multiple contraindicationsinolderpeople
Step three
•Opiates- be aware of side effectsandfallsrisk

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Recommended reading
Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L,
Schofield P; (2013). Guidance on the management of pain in older people Age Ageing 42
(suppl 1): i1-i57
http://ageing.oxfordjournals.org/content/42/suppl_1/i1.full?sid=0ff4d625-b94f-4869-9eb8-
faeec198136d
Accessed 31st December 2015
American Geriatrics Society (2012). American Geriatrics Society updated Beers Criteria for
potentially inappropriate medication use in older adults. American Geriatrics Society. New
York
http://www.guideline.gov/content.aspx?id=37706
http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
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http://ageing.oxfordjournals.org/content/42/suppl_1/i1.full?sid=0ff4d625-b94f-4869-9eb8-
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Abstract Managing_pain_in_the_older_person

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