IAGS

39:64-73, 2992

PROGRESS IN GERIATRICS

Pain Management in Elderly People Bruce A. Ferrell, MD*

atient comfort and the control of pain are im- home residents, the prevalence of pain may be even portant goals in geriatric care. Pain is the most higher; estimates range from 45% to 80%8*14-15 with a common symptom of disease and the most predominance of musculo-skeletal causes of pain, escommon complaint in physicians' offices.' pecially osteoarthritis. Indeed, it is recognized that However, the management of chronic pain can be arthritis may affect 80% of people over age 65, and perplexing for physicians. With no objective biological most suffer significant pain.16 Cancer is another immarkers for pain, assessment remains based on the portant source of pain in this age group.I7 One-third patient's perceptions and self-report, and these are of cancer patients with active disease and two-thirds often clouded by individual interpretation of sensation, with advanced disease have significant pain. A number affective reactions, and behavioral responses. Several of other specific pain syndromes are known to affect studies have documented that many physicians and the geriatric population disproportionately, including nurses lack information about pain assessment and herpes zoster, temporal arteritis, polymyalgia rheumamay have an inaccurate knowledge base about com- tics, and atherosclerotic peripheral vascular disease." mon pharmacological agents used in pain Surprisingly little attention has been focused on the Consequences of pain are widespread in the elderly global issue of pain management in geriatric medicine. population. Depre~sion,~-~ decreased so~ialization,~-' Of 11 leading textbooks of geriatric medicine,''-29 only sleep di~turbance,~ impaired amb~lation,~-'and in- tWo19-20 have devoted chapters to the approach and creased health care utilization and costs' have all been management of pain. A review of eight geriatric nursassociated with the presence of pain among elderly ing textbooks reveals less than 18 pages devoted to people. Though less thoroughly explored, decondition- pain relief out of 5,000 total pages of text.30If a major ing, gait disturbances, falls, slow rehabilitation, poly- goal of geriatric care is the comfort and control of the pharmacy, cognitive dysfunction, and malnutrition are symptoms of chronic disease, we can no longer afford among the many geriatric conditions potentially wors- to ignore the problem of pain in the elderly population. ened by the presence of pain. Finally, pain and its PATHOPHYSIOLOGY OF PAIN management have major implications for quality of life Theories of pain as a simple sensation have long ago and quality of care, especially for terminal patients" been abandoned. Pain is now recognized as a complex and residents of long-term-care facilities.' experience derived from sensory stimuli but modified Pain is extremely common among older people. Popby individual memory, expectations and emotions.31 ulation-based studies have estimated that 25% to 50% of community-dwelling elderly people suffer important Neuroanatomic and neurochemical findings overpain problems."-'3 In a survey by Crook et a1 of 500 whelmingly support the gate Control Theory of pain randomly selected households in Burlington, Ontario, perception as first described by Melzack and Wall.32 16% of the total population aged 18 to 105 reported a The gate theory postulates that sensory information "significant" painful problem in the preceding 2 weeks. can be inhibited at the spinal level. As depicted in In this study, the incidence of pain was twice as great Figure 1, essentially two types of sensory information (250 per thousand vs 125 per thousand) in those over are relayed through lateral spinothalamic tracts of the age 60 than in those 60 and under." Among nursing spinal cord to the cerebral cortex and conscious areas of the brain. The fast tract relays phasic information directly to the cortex, including location and quantitative qualities such as "severe," "sharp" and "sudden". * From the UCLA School of Medicine, VAMC Sepulveda GRECC, The slow tract relays tonic information to the brain and Sepulveda, California. is believed to give rise to affective and emotional Address correspondence to Bruce A. Ferrell, MD, VAMC Sepulcomponents of chronic pain via connections to the Veda GRECC (IIE), 16111 Plummer Street, Sepulveda, CA 91343.

P

01991 by the American Geriatrics Society

0002-8614/91/$3.50

PAIN MANAGEMENT IN THE ELDERLY

1AGS-JANUARY 1991-VOL. 39, NO. 1

Pain Sensation

65

limbic system. The slow tract is thought to produce such descriptions as "burning," "frightening," or "cruel". A pain inhibitory system also exists which influences sensory information at the spinal level. With connections from the limbic and higher cortical areas, this system descends from the midbrain to the spinal cord Limbic and appears to be extremely important in the moduSystem lation of pain sensation. It may be through this descending inhibitory system that many complex painrelated effects may be explained, including the effects of tricyclic antidepressants, transcutaneous nerve stim- Rapid Conduction ulation (TENS) therapy, acupuncture and placebos.33 (Phasic Pain) The identification of specific neurotransmitters in Slow Conduction (Tonic Pain) pain perception has added to our knowledge of pain mechanisms. Table 1 lists neurotransmitters that have been identified within pain pathways. Their function in modulating pain perception is elaborate and complex. Specific transmitters may enhance or inhibit pain information. For example, serotonergic antidepressants seem to excite the descending pathway that inhibits FIGURE 1. Diagram showing the major nervous system certain kinds of pain perception at the spinal level. connections in the perception of pain. Endogenous opioid mediators (eg, endorphins, enkephalins, and dynorphins) have been identified with at least five types of opiate receptors, elaborating many of the observed effects of opiate drugs including pain TABLE 1. NEUROCHEMICAL MEDIATORS relief, central nervous system (CNS) excitement, euIDENTIFIED IN PAIN MECHANISMS phoria, and narcosis.34 Asending pathway (dorsal horn neurons) Age-associated changes in pain sensation have been Substance P a topic of interest ever since elderly people have been Neurotensin Cholecystokinin observed clinically to present with unusual manifestaSomatostatin tions of acute illness. For example, older patients often Descending pathway (midbrain and spinal cord) have painless myocardial infarction^^^ and intra-abSerotonin dominal catastrophe^.^^-^^ Whether these clinical obNorepinephrine Gamma aminobutyric acid (GABA) servations represent a distinct age-related change in Glycine pain perception remains contro~ersial.~~ Studies using Acetylcholine a variety of methods to induce pain in "normal" volAssorted areas (brain, cord, nerves and ganglia) unteers have given mixed results. Table 2 summarizes Opiate receptors (5 types) a few of these s t ~ d i e s . In ~ ~an- ~ elegant ~ review of this Endogenous Opoids Endorphins subject, Harkins, Qwentus, and Price4' concluded that Enkephalins due to differences in methodology and subject selecDvnomhins tion, a consensus does not exist in the literature regardTABLE 2. AGE ASSOCIATED CHANGES IN PAIN PERCEPTION FROM INDUCED PAIN STUDIES Threshold Tolerance Investigator Change Change (reference) Stimulus with Aging with Aging

Schumacher, 194039 Birren, 1950" Sherman, 196441 Mumford, 196642 Collins, 196843 Clark, 197144 Woodrow, 197245

ThermallSkin TherrnallSkin TherrnallSkin Shock/Tooth Shock/Skin Thermal/Skin

No change No change

Lower Higher

NA NA NA NA Lower NA

Achilles tendon

NA

Lower

Harkins, 197746 Tucker, 198947

pressure Shock/Tooth Shock/Skin

No change

NA NA

NA, Not addressed.

Higher No change

Higher

66

FERRELL

ing age-associated changes in pain perception. Thus age-related changes in pain sensitivity and tolerance remain difficult to document and are of questionable clinical significance since induced pain may not be analogous to the clinical experience of pain.48 The consequences of stereotyping most elderly people as always experiencing less pain may include needless suffering and decreased quality of life. EVALUATION OF PAIN IN ELDERLY PEOPLE Clinically, it is helpful to categorize pain as either acute or chronic. Acute pain is defined by its distinct onset, obvious pathology, and relatively short duration. Acute pain is usually associated with autonomic activity such as tachycardia, diaphoresis, or mild hypertension and implies the existence of endangering injury and remedial disease. Chronic pain is defined as having a duration of more than 3 months. Chronic pain has no autonomic signs, is usually out of proportion to the immediate danger, and is associated with long-standing functional and psychological impairment. Because pain is such an individual experience, a multidimensional approach to assessment is usually required. Physical, functional, and psychological evaluation should be combined to ensure accurate assessment.49 This section will review salient features of multidimensional pain assessment including the use of specific pain-assessment scales. Evaluation of pain begins with a thorough history and physical examination. Because of the frequency with which problems occur in older people, special attention should probably be directed at the musculoskeletal and nervous systems.s0 The history is important to establish the medical diagnosis and a baseline description of the pain experience. Most clinicians are familiar with the "what, when, where, and how" diagnostic approach to the pain complaint. For the frail elderly, any history of trauma should be thoroughly evaluated. Finally, sudden changes in the character of the pain may indicate deterioration or new injury and should be carefully evaluated. It is important to remember that elderly patients may present special problems in obtaining an accurate pain history. Failures in memory, depression, and sensory impairments may hinder history-taking. More importantly, they may under-report symptoms because they expect pain associated with aging and their diseases.49 Cancer patients may not report pain because they fear the meaning of pain or because they think pain cannot be relieved. Many elderly patients may not report pain because they "just don't want to bother anyone," despite having severe pain affecting their mood and functional status.8 Finally, the importance of family and caregvers as a source of information about elderly patients cannot be overemphasized.

JAGS-IANUARY 1991-VOL. 39, NO. 1

Because elderly patients suffer concurrent illness, care must be taken to avoid attributing new pain to pre-existing chronic illness. Making this problem worse is the fact that chronic pain is usually not constant. Both the character and intensity of chronic pain may fluctuate with time. Injuries due to trauma as well as other acute arthritis (eg, gout or calcium pyrophosphate arthritis) are easily overlooked in this setting. Only astute questioning and comprehensive evaluation will avoid these pitfalls. Physical examination should serve to confirm suspicions elicited by the history as well as help evaluate functional limitations. Important during the physical examination is palpation for trigger points and inflammation. Trigger points may result from tendonitis, muscle strain, or nerve irritation. Specific maneuvers that reproduce the pain, such as straight-leg-raising and joint motion may be useful in diagnosis as well as functional assessment. Additionally, a thorough neurologic examination should be conducted, including attention to signs of autonomic, sensory, and motor deficits suggestive of neuropathic conditions and nerve injuries.49 Evaluation of function is important so that mobility and independence can be maximized for elderly patients in pain.51 Functional assessment may include information from the history and physical examination as well as several available functional assessment scales. Scales frequently used in routine geriatric evaluation, such as the Tinetti gait evaluation scales2 and the L a ~ t o nand ~ ~the Katzs4 activities of daily living scales may be useful. However, at least two studies in elderly people have suggested that advanced activities of daily living and "elective" activities such as ambulation and psychosocial functions may correlate better with the presence and severity of pain.'-' Psychological evaluation should be conducted because psychological problems are strongly associated with chronic pain.55 Most patients with chronic pain will have significant depressive symptoms at some time and may benefit dramatically from psychological or psychiatric intervention. Likewise, anxiety may be a significant factor in the management of chronic pain. Clinical evidence suggests that cognitive impairment may be exacerbated by pain and its treatment. Psychological assessment should include at least a thorough mental status examination and an evaluation for depression. The Folstein Mini-mental State E ~ a m i n a t i o n for ~ ~ cognitive impairment and the Hamiltons7or Y e ~ a v a g escales ~ ~ for depression may be used for screening purposes. Formal psychological tests including the Minnesota Multiphasic Personality Inventory (MMPI), which has been validated for use in older populations, may also be useful in some patients by identifying personality traits that might benefit from specific psychological or psychiatric therapy.s9

PAIN MANAGEMENT IN THE ELDERLY

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67

proach to the Management of Pain,”63and the World Health Organization’s guidelines for pain management among terminally ill patients.64Over the last 15 years, the success of specialized pain centers and multidisciplinary pain teams, and the development of hightechnology pain-management methods (eg, morphine pumps and chronic spinal infusions) have defined a variety of options in pain management. In spite of the fact that pain management may entail special problems in elderly patients, few studies exist describing pain management strategies specifically for older people. For the most part, information has been extrapolated from experience in younger patients and those with pain due to cancer. The control of most acute pain relies initially on treatment of the underlying disease and short-term administration of analgesic drugs. Chronic pain, on the other hand, usually requires a multidimensional approach of non-pharmacologic strategies as well as analgesic and adjuvant drug treatment.65 Table 3 lists initial pain-management strategies based on the type of pain and its severity. Patients with malignant pain usually respond well to constant administration of opiate analgesics. However, long-term use of narcotic analgesics for chronic non-malignant pain remains more controversial and should be reserved for more severe pain or only after other apPAIN MANAGEMENT proaches have failed. It is also important to remember Pain management has reached a high level of so- that neuropathic pains, such as herpes zoster and postphistication, as evidenced by the National Institutes of stroke thalamic pain, do not usually respond well to Health Consensus Conference, “The Integrated Ap- analgesic drugs but may respond to tricyclic antide-

Both qualitative and quantitative pain assessment scales (such as the McGill Pain Questionnaire) have been developed to help clinicians and researchers measure, more accurately document, and communicate patients’ pain experiences.60Figure 2 illustrates some of the pain assessment instruments that may be adapted for clinical use among elderly. Qualitative instruments, such as pain diaries, pain logs, pain graphs, or direct observation may be helpful clinically. These methods provide the physician with a description of the patient’s individual pain experience and can be particularly useful in determining overall effectiveness of pain managemenh6’ Recent work has assessed behavioral responses to pain, such as facial grimaces and agitation, as valid indicators of pain;62this will be an important area for further study because cognitively impaired patients may be unable to communicate their pain in words. Scales attempting to quantify the intensity of patients’ pain are unidimensional and are attractive because of their ease of use and face validity. It is important to remember, however, the words of Dr. Ronald Melzack, “To describe pain only in terms of intensity is like specifying the visual world only in terms of light flux without regard to pattern, color, texture, and many other dimensions of the visual experience.”60

Pain Assessment Instruments

Lz2:.

I

I

f40hN

i

MtID‘PIIN

UISCOM:OHIINC

OISIR&G

IN,:N~E

u[R:(IB~~‘

FIGURE 2. Chart showing an example of four types of pain assessment scales: a pain diary, a pain word descriptor, a visual analog scale, and an observational behavior scale.

68

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1AGS-IANUARY 1991-VOL. 39, NO. I

pressants or anticonvulsant drugs. Moreover, the use of combined pharmacologic and non-pharmacologic techniques usually results in more effective pain control with less reliance on medications having major side effects in the e l d e r l ~ . Finally, ~ ~ , ~ ~the importance of reassessment to estimate relief of pain and look for the emergence of side effects cannot be overstated. Multiple trials with various combinations of drug and nondrug strategies may be required for optimal pain relief. Analgesic Drugs i n Older Patients-The most common treatment of pain is the use of oral or injectable analgesic medications. Analgesic drugs are considered in two broad categories: non-steroidal anti-inflammatory drugs (NSAID) (some authors include acetaminophen in this category, although it has little antiinflammatory activity) and opiate analgesic drugs. A review of individual drugs is beyond the scope of this

paper, many such articles already exist.33,66-69 Several important generalizations, however, should be considered when prescribing analgesic drugs. Non-steroidal anti-inflammatory drugs act peripherally in the nervous system; they affect pain receptors, nerve conduction, and inflammatory conditions which may stimulate pain.67 Table 4 lists characteristics of some common NSAIDs along with special considerations for their use in elderly patients. Individual drugs in this class vary widely in their analgesic properties, metabolism, excretion, and side effect profiles. In addition, the analgesic activity of these drugs is characterized by a ceiling effect,67that is, a level at which increasing the dose results in no further increase in analgesia. These drugs often work well, given alone or in combination with narcotic analgesics, for metastatic bone pain and inflammatory conditions and have no

TABLE 3. SUGGESTED INITIAL PAIN MANAGEMENT STRATEGIES FOR ELDERLY PEOPLE Pain Neuropathic Type Musculoskeletal Pain Pain Malignant Pain Mild

Moderate

Severe

Aspirin/Acetaminophen NSAID* HeatICold Physical Therapy Local Injection Cognitive Therapy TENS Acupunture Codeinelweak Opiate Combinations Strong Opiates

Aspirin/NSAID* Local Injection

AspirinIAcetaminophen Cognitive Therapyt

Antidepressant Anticonvulsant Weak Opiate Combinations Neuro-ablation Strone Ouiates

Codeine Weak Opiate Combinations Strong Opiates

* Non-steroidal anti-inflammatory drugs. biofeedback, etc.

t Relaxation, distraction,

TABLE 4. EXAMPLES OF NON-STEROIDAL ANTI-INFLAMMATORY DRUGS FOR MILD TO MODERATE PAIN IN ELDERLY PERSONS Analgesic Maximum Dose Comments Dose Daily Dose Interval Drug I

Aspirin Acetaminophen Diflunisal (Dolobid) Ibuprofen

500-1000 mg 500-1000 mg

4000 mg 4000 mg

4-6 hr 4-6 hr

Standard NSAI Hepatotoxic, No gastric toxicity

1000 mg Init.* 500 mg Sub.t 200-400 mg

1500 mg

8-12 hr

Superior analgesia to aspirin

2400 mg

4-6 hr

Superior analgesia to aspirin

1250 mg

6-8 hr

Comparable to aspirin

100 mg

8-12 hr

Not often used due to high incidence of side effects

Indomethacin

500 mg Init. 250 mg Sub. 25 mg

Sulindac (Clinaril)

150 mg

400 mg

12 hr

Less renal toxicity

Salsalate (Disalcid)

1000 mg

3000 mg

8-12 hr

Trisalicylate (Trilisate)

1000 mg

3000 mg

12-24 hr

Less GI erosion; less platelet disfunction Less GI erosion

Naproxen

* Initial Dose; t subsequent dose. Modified from: Principles of Analgesic Use in the Treatment of Acute Pain and Chronic Cancer Pain, 2nd Ed., Skokie, IL: American Pain Society, 1989.

IAGS-JANUARY 1991-VOL. 39, NO. 1

habit-forming properties of their own. However the NSAIDs have been associated with a variety of adverse effects in the elderly, including peptic ulcer disease,70 renal insufficiency,” and bleeding diathesis.66 Although previously considered the safest form of analgesia for mild to moderate pain, recent studies are beginning to question their overall safety when used by frail elderly patient~.~’-~l Opiate analgesic medications when administered systemically act on the central nervous system (brain and spinal cord) to decrease the perception of pain.33 Some of these drugs (including morphine) may also act as local anesthetics and have recently found widespread use in epidural admini~tration.~’ Opiate drugs have no ceiling to their effects and have been shown to relieve all types of pain (although they appear less effective in the chronic management of neuropathic pain compared to pain from other causes).69Short-term studies have shown that elderly patients are more sensitive to the pain-relieving properties of these drugs than are younger patients. This is true for po~toperative~ as~well - ~ ~ as chronic cancer pain.75Advanced age is associated with a prolonged half-life and altered pharmacokinetic~.~~ At least one study has noted enhanced analgesia in elderly women compared to younger women even when morphine was administered by the epidural route.76Thus, elderly patients may achieve pain relief from smaller doses of opiate drugs than younger patients.77However, recent longitudinal studies by Sorkin et al,78Middaugh et al,79and our groupso have not reported age-associated changes in chronic pain or its management. These conflicting observations may be related to drug pharmacokinetics, study design, or altered reporting of pain among elderly subjects. Opiate drugs have the potential to cause cognitive disturbances, respiratory depression, constipation, and habituation among older persons. Clinical experience suggests that opiate drugs (as with most psychoactive drugs) may produce paradoxical effects. Morphine remains the standard to which all other analgesic drugs are compared. When administered appropriately, morphine’s effects remain the best understood and most predictable. Melzack considers morphine the strong opiate of choice for severe pain.33In the same article, he suggests that our reluctance to prescribe morphine has been overly influenced by recent political and social pressure against illicit drug use among people who take drugs for emotional rather than medicinal reasons.33In a review of 12,000 medical records by Porter and Jick, there were only four cases of opiate dependency in patients taking opiate drugs (excluding patients with previous drug addiction).81This does not imply that morphine and other opiates can be used indiscriminately, only that dependency and other side effects do not justify a failure to treat pain in elderly patients.

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69

It is important to remember that tolerance has special implications for opiate prescribing. Tolerance is present when an effect of the drug disappears over time as the subject is continuously exposed to the drug. Tolerance to side effects of opiates may have the beneficial effect of reducing the risk of respiratory depression and drowsiness. Analgesic drugs should be administered on a continuous basis (as opposed to PRN or “as needed”) whenever possible because it is now recognized that when tolerance develops to the side effects of drowsiness and respiratory depression, the result is more effective analgesia and reduced overall drug con~ u m p t i o n Tolerance .~~ to side effects develops much faster than tolerance to analgesia; thus an effective dose may remain stable for many months.33 Some side effects of opiates, such as constipation and nausea, do not diminish with time, and these may make overall pain management more difficult. It is important to begin bowel regimens when opiates are first started. Increased fluids, bulk agents, lubricating agents, and bowel stimulants may be required while opiates are administered. Nausea results from dlrect stimulation of the chemoreceptor trigger zone in the brain. Although antihistamine and phenothiazine antiemetic drugs have been the mainstay for preventing nausea in younger patients, it is important to remember that elderly patients are especially likely to develop anticholinergic side effects, delirium, and movement disorders.82 A variety of opiate drugs is available, and they differ widely with respect to analgesic potency and side effects among the elderly. Table 5 lists characteristics of some of the available opiate drugs along with special considerations for their use among the elderly. Because of particular problems in the elderly, at least three opiate drugs require special mention. Propoxyphene (Darvon) is a controversial drug that is probably overprescribed in the elderly. Reports suggest that its efficacy is no better than aspirin or acetaminophen, and it has significant potential for addiction as well as renal injury.83Pentazocine (Talwin) is an opiate drug that should be avoided because it frequently causes delirium and agitation in the elderly. This effect seems to be related to the drug’s mixed agonist/antagonist opiate receptor activity.84 And finally, long-acting opiates such as methadone should be used with extreme caution because of the propensity for drug accumulation in the frail elderly. Adjuvant analgesic drugs are medications without inherent analgesic properties themselves which have been found to be helpful in treating certain types of chronic pain. These drugs include antidepressants, anticonvulsants, and some sedatives. For example, treatment of underlying depression or mood disorders may enhance other pain-management strategies. Tricyclic anti-depressants and anticonvulsants are often helpful

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JAGS-JANUARY 1992-VOL. 39, NO. 2

in controlling neuropathic pain in tic douloureux, herpes zoster, diabetic neuropathies, and thalamic (poststroke) pain syndrome^.^^ Finally, mild sedatives or tranquilizers are helpful in reducing anxiety, stress and tension and allowing the patient to get a good night’s sleep. Chronic pain is an exhausting experience, and patients cope better with adequate sleep. Table 6 lists salient principles of pain management among elderly people. Although older persons are generally more sensitive to the analgesia and the sideeffects of all of the drugs described above, guidelines for age-based adjustment of initial doses and incremental increases remain largely based on clinical judgment. In the final analysis, the old adage ”start low and go slow” remains the best rule. Non-pharmacologic Pain Management-Advances in pain-management have strongly supported the combination of drug and non-drug strategies for pain relief. We shall discuss physical therapy, TENS therapy, biofeedback, hypnosis, and distractive techniques. Indeed, clinical experience suggests many of these techniques are quite effective in individual cases. Physical methods including heat, cold and massage are very useful in the management of pain. These measures relax tense muscles and are soothing for a variety of complaints. Many of these methods can be self-applied, thus gving the patient and family a sense of control over symptoms and treatment. However,

caution must be taken to avoid thermal bums during prolonged use of either heat or ice. Physical therapy directed at stretching and strengthening specific muscles and joints may also be useful in improving muscle spasm and allowing enhanced functional activity. Referral to a trained physical therapist may be appropriate for safe and effective rehabilitation from many painful conditions. TENS therapy has been used successfully in a variety of chronic pain conditions in older patients. Painful diabetic neuropathies, shoulder pain or bursitis, and fractured ribs have been shown to respond to TENS therapy. Overall, the effectiveness of TENS has been variable and usually diminishes with time although some patients have been relieved for years.85A recent controlled study was only able to show a placebo effect associated with TENS.86 An important issue in the success of TENS therapy is the appropriate placement of the electrodes and current adjustment. This involves meticulous searching for the best settings for an individual’s optimum comfort. Also, care must be taken to avoid skin irritation and possible bums from the electrodes, especially among the cognitively impaired. A variety of psychologic maneuvers may be quite effective in controlling pain. Biofeedback, relaxation, and hypnosis may be helpful for some patients. These methods usually require high levels of cognitive function and therefore may not lend themselves to patients

TABLE 5. EXAMPLES OF ORAL OPIATE ANALGESIC DRUGS FOR MODERATE TO SEVERE PAIN IN ELDERLY PERSONS Relative Suggested Dose Drug Oral Potency Starting Dose* Interval Comments Morphine Codeine (Tylenol #3)

30 mg 60 mg

20-30 mg 30-60 mg

3 hr 3 hr

Oxycodone (Percodan) Hydromorphone (Dilaudid) Meperidine (Demerol)

5 mg 2 mg 50 mg

5 mg 1-2 mg 25 mg

3 hr 2-3 hr 2-3 hr

Standard for comparison Combinations with aspirin or acetaminophen limit dose Increased delirium Shorter duration than morphine Transformed to toxic metabolites causing CNS excitement Plasma half-life >36 hr in older people Drug accumulation is significant in 2-3 days

24 hr 2-5 mg Methadone (Dolophine) 2 mg 12 hr 2-4 mg Levorphanol (Levo-Dromoman) 2 mg * Physicians should take into account whether the patient has had prior exposure to opiates and adjust dose accordingly.

Adapted from: Principle of Analgesic Use in the Treatment of Acute Pain and Chronic Cancer Pain: A Concise Guide to Medical Practice, 2nd Ed. Skokie, IL: A m Pain SOC, 2989.

TABLE 6. PRINCIPLES OF PAIN MANAGEMENT FOR ELDERLY PEOPLE 1. Always ask elderly patients about pain. 2. Accept the patient‘s word about pain and its intensity. 3. Never underestimate the potential effects of chronic pain on a patient’s overall condition and quality of life. 4. Be compulsive in the assessment of pain. An accurate diagnosis will lead to the most effective treatment. 5. Treat pain to facilitate diagnostic procedures. Don’t wait for a diagnosis to relieve suffering. 6. Use a combined approach of drug and non-drug strategies when possible. 7. Mobilize patients physically and psycho-socially. Involve patients in their therapy. 8. Use analgesic drugs correctly. Start doses low and increase slowly. Achieve adequate doses and anticipate side effects. 9. Anticipate and attend to anxiety and depression. 10. Reassess responses to treatment. Alter therapy to maximize functional status and quality of life.

IAGS-IANUARY 1991-VOL. 39, NO. 2

with significant cognitive impairment. A trained psychologist or therapist should probably be consulted for these techniques. Finally, a variety of distractions may be effective in decreasing the perception of pain. Many patients find comfort in prayer, meditation, or music.87Involvement in activities, exercise, and recreation should be encouraged as much as tolerated. Inactivity and immobility may contribute importantly to depression and worsening of pain. Centers for pain management and rehabilitation have been effective in the multidimensional management of patients with pain.78-79Their success appears to be related to the ability to provide an interdisciplinary prescription for individual pain problems. They usually can enlist physicians, nurses, rehabilitation therapists, psychologists, and social workers in in-patient or out-patient settings. Although the experience of most of these centers with the old-old (age >85) age group is limited, pain center referral is probably appropriate for the majority of older chronic pain patients with significant functional and psychological impairments.88 High-technology Pain Management-Recent developments in pain management have focused on a variety of drug delivery systems for the management of pain. Infusion pumps can supply continuous or intermittent analgesic drug infusions via subcutaneous, IV, or intraspinal routes. Some pumps are fully programmable, allowing patients to titrate medication (within limits programmed by the physician). With appropriate supervision and patient education, this technology has become feasible in selected case^.*^-^^ Continuous morphine infusions may be expensive. Three thousand dollars a month is not uncommon for pump rental, pharmacy preparation fees, and added suprevision by nurses, pharmacists, or physicians. If not for the inconvenience and catheter-related risks, spinal infusion of opiates might be very attractive because total dosages and systemic toxicity may be minimized by this route. Opiate drugs infused epidurally block pain perception without much impairment of cognitive function or bowel and bladder function. Duration of analgesia may be prolonged by this route 6-24 hours for one injection of morphine has been reported." However, it is still relatively short, and frequent injections or continuous infusion may be required for chronic pain management. A variety of chronic indwelling devices are now available for this purpose.92Subdural and intrathecal injections require skill to administer, and complications have been reported including migration of catheters, CNS infections, and death. For this technology to be widely applied, it is essential that advantages outweigh risks. Thus far, there is little conclusive evidence that opiates injected epidurally or intrathecally produce analgesia

PAIN MANAGEMENT IN THE ELDERLY

71

superior in quality to other routes of administration; (93) they should be reserved for situations where all other routes have failed. Although these procedures have been effective in selected cases, more work needs to be done to define the role of these technologies for their use among elderly patients. The usual approach is to consider "high-tech" strategies only after failure of oral medications and all other treatments. Whether these technologies have risk-benefit ratios sufficient to justify their use for routine postoperative pain, non-malignant pain, or less intense pain syndromes is very uncertain. Although most of these techniques are expensive, they are reimbursable by Medicare and other insurers. The possibility exists that reimbursement policies are playing a role in decisions to apply "high-tech" pain-management techn~logies.~~ SUMMARY AND FUTURE DIRECTIONS Pain is a common problem that has tremendous potential to influence the physical function and quality of life of elderly people during their remaining years. It is unfortunate that so little geriatric research and education has focused on this important topic. If functional preservation and quality of life are salient goals of geriatric care in the United States, the effective assessment and management of pain must be recognized as a fundamental care issue as it has been in Great Britain, Canada, and other nations with organized geriatric health care systems. Much research and education are needed to further our understanding of pain and its management among elderly people. Geriatric education programs should emphasize objectives for comfort and control of pain. Although the identification of a biological marker for pain will remain the "Holy Grail" in pain research, valid and reliable proxy measures such as functional status, pain questionnaires, coping, and behavioral observations need to be investigated for the elderly population. Increased attention should be directed toward strategies for arthritis and non-malignant pain syndromes. New drugs with milder side effect profiles are urgently needed. Implications, indications, and applications for "high-tech" pain-management strategies, such as morphine pumps and chronic spinal infusions, need to be clarified in older people. And finally, the long-term outcomes of pain-management strategies need to be evaluated and compared. REFERENCES Maciewicz R, Martin JB: Pain: Pathophysiology and management, in Braunwald E, Isselbacher KJ, Petersdorf RG, et al, (eds): Hamson's Principles of Internal Medicine, 11th Ed. New York, McGraw-Hill, 1987 Bonica JJ: Pain Research and Therapy: Past and current status and future needs, in Ng L Bonica JJ (eds): Pain and Discomforf. Amsterdam, Elsevier, 1980 Weis OF, Sriwatanakul K, Alloza JL, et al: Attitudes of patients,

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