EDITORIAL
For reprint orders, please contact: [email protected]
Working with older adults to manage pain
Pat Schofield†
“Instead of proposing pain-management strategies based upon guidelines and experience, we need to listen to what the older adults are using themselves and provide them with the skills to identify evidence of efficacy and where this does not exist to develop ways of evaluating such approaches themselves.”
The population is aging; it is anticipated that the age distribution over 65 years will rise to 36% by 2050 and with the potential to live longer it has been suggested that we will see the over 80-year age group triple in numbers. With the frequency of pain being reported to be as high as 73% amongst community-dwelling older adults, and this figure increasing to 80% for those living in care homes, there is the potential for an aging pain ‘time bomb’ in the next three decades. This does not just relate to chronic pain; studies also demonstrate that acute pain is also poorly managed in this group [1] . Furthermore, 67% of cancer deaths occur in those over the age of 65 years and with cancer often comes pain [2] . There has been some discussion as to whether or not there is evidence of physio logical changes within pain processing attributable to age [3] . Certainly, there is some evidence that chronic pain is more prevalent in older adults along with some suggestion that altered physiology of peripheral and central pain mechanisms combined with psychological attitudes such as stoicism and reluctance to confirm
the presence of pain are all key factors [3] . Some take the perspective that pain is present in the same format irrespective of age [4] . So it may be that we need to consider the psycho–socio–cultural factors in the management of any individual experiencing pain, regardless of their age, and this approach requires a multidimensional perspective. However, we should not assume that getting older will increase the risk of being in pain or reduce the ability to cope with pain, as we have world leaders who are still active and important members of society whilst in their 80s. By contrast, others in this age group may be frail and suffering, thus suggesting that there is no uniform process in aging and pain. Poorly relieved pain is an important cause of functional impairment in any age group. With this we see reduced mobility, decreased socialization, sleep disturbance, slow rehabilitation and consequently increased healthcare utilization and costs. However, with older adults, such impact also precipitates social isolation that can lead to increased symptoms, such as depression and increased cognitive impairment [5] . A recent review of the literature
“The population is aging; it is
anticipated that the age distribution over 65 years will rise to 36% by 2050…”
Centre for Advanced Studies in Nursing (CASN), Centre of Academic Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen, AB25 2AY, UK Tel.: +44 122 455 4854; Fax: +44 122 455 0683; [email protected] †
10.2217/PMT.10.8 © 2011 Future Medicine Ltd
Pain Manage. (2011) 1(1), 11–13
ISSN 1758-1869
11
Editorial Schofield
“With the frequency of
pain being reported to be as high as 73% amongst communitydwelling older adults, and this figure increasing to 80% for those living in care homes, there is the potential for an aging pain ‘time bomb’ in the next three decades.…”
12
on the experiences of chronic pain in older adults highlighted a number of key issues [6] . For example, the main focus was on the effects of chronic pain on people’s daily lives and their ways of adjusting and coping with chronic pain within the community environment. Klinger et al. found that older people in the community adapted nearly half of their daily activities when experiencing pain, whilst less important tasks would be stopped altogether [7] . Other studies indicate that older people do not consider their pain to be a great problem; it was the effect pain had on their daily lives that seemed most problematic [8] . Furthermore, the qualitative literature suggests that older people link aging to physical decline and being in pain, and therefore they may be reluctant to seek help. This has also been found in the nursing home setting where, because older people believed their pain to be intractable, they often did not complain to staff [6] . Some authors describe a process of normalization where older women learn to ‘get on with it’ and develop their own management strategies [9] . Methods of coping identified include: spending time with family and friends, and diversional activities, such as reading and watching the television. Rest and other interventions such as heat or ‘folk’ remedies are cited as being used, with medication only taken as a last resort [7,10] . One author found that older people preferred self-administered strategies for managing their pain (e.g., massage and informal cognitive coping strategies) [11] . Traditional methods such as medication, physiotherapy and exercise were least preferred [10] . It was also noted that older people appreciate being actively involved in the management of their pain, presumably because this provides them with a sense of control. Older adults seldom use approaches to manage their pain that are perceived to be helpful in the younger population, for example relaxation, muscle relaxation and imagery. However, it has been suggested that there are a wide variety of barriers to effective management of pain within this population and these are associated with the healthcare system or professionals. Furthermore, further barriers have been cited as existing amongst the older adults themselves. For example, one study has identified barriers such as fear of falling and restrictions due to disability associated with failure to participate in exercise. A further more focused study by Austrian et al. identified 17 barriers to participation in painmanagement programs, which they grouped into
Pain Manage. (2011) 1(1)
three main categories: access, internal attribution and program-specific issues [12] . They suggested that some of the barriers identified were linked to the individual having a ‘lack of control over one’s life’. They did acknowledge that there were some limitations in this study but suggested future work needed to look at how to engage older adults in the pain-management process. Further studies have shown that self-management strategies are associated with better coping, and lower levels of pain-related disability and healthcare use [13] . So how can we engage with older adults to enable this process of improved self-management of pain? One perspective may be to enable a sense of control, as research suggests that older people are more concerned with well-being, prevention of illness and quality of life. This would suggest working with older adults to manage pain as opposed to managing their pain for them. But in order to do this we need to determine what strategies for pain management are preferred by them and subsequently establish the evidence underpinning such approaches. This requires a change in perspective on the part of the healthcare professionals. Instead of proposing pain-management strategies based upon guidelines and experience, we need to listen to what the older adults are using themselves and provide them with the skills to identify evidence of efficacy and where this does not exist, to develop ways of evaluating such approaches themselves. This is work that is ongoing within Aberdeen. This means ‘involving service users’ more actively and collaboratively. The patient, public involvement (PPI) movement is growing and developing fast, and we are seeing more and more emphasis on involving service users not only in advising on research projects, but helping to develop them and identifying priority areas. Thus, it would be reasonable to enlist the help of older adults and ask them to identify what is important for them and how they feel their pain should be managed, and enable them to access the evidence and determine what further research needs to be done, which is what we have been doing for the past 2 years. Two issues arise from this approach that must be acknowledged. First, whilst a recent systematic review on the use of PPI [101] does identify some beneficial impacts of PPI, it also identifies some negative impacts, including those upon policymakers, researchers and the participants themselves. Costs, training, time and difficulties with publishing have all been listed as challenges with this approach [101] .
future science group
Working with older adults to manage pain Furthermore, participants themselves can find it challenging as they can feel that they are not listened to or become frustrated that researchers assume they have no knowledge [14] . Often such an emphasis has led to the ‘lip service’ approach to PPI where service users are invited to sit on advisory boards but their opinions not considered important or given the time to be heard. A second challenge with involving older adults in managing their own pain is more fundamental within the pain world itself and relates to the definition of self-management, which appears to be causing some controversy. Management of many chronic illnesses require that the individual or their carer takes extensive responsibility for their own management and as suggested by Barlow et al. [15] , self-management needs to enable the individual to “monitor their own condition and the impact that it may have upon quality of life”. A recent review of the literature identified 63 studies for a range of chronic illnesses including chronic pain-related conditions. The term self-management has been used loosely to describe a variety of programs where the patient plays an active role in the treatment program [16] . However, a dilemma exists when Bibliography 1
2
3
4
5
6
7
Desbiens NA, Mueller-Rizner N, Connors AF: Pain in the oldest old during hospitalisation and up to one year later. J. Am. Soc. Geriatr. Dent. 45, 1167–1172 (1997). D’Agostino NS, Gray G, Scanlon C: Cancer in the older adult: understanding age related changes. J. Gerontol. Nurs. 16, 12–15 (1990). Gibson SJ, Weiner D (Eds). Pain in Older Persons, Progress in Pain Research and Management. IASP Press, Seattle, WA, USA, 35, 67–85 (2005). Sorkin BA, Rudy TE, Hanlon RB, Turk DC, Stieg RL: Chronic pain in old and young patients: differences appear less important than similarities. J. Gerontol. 45(2), 64–68 (1990). Casten RJ, Parmelee PA, Kleban MH, Lawton MP, Katz IR: The relationships among anxiety, depression, and pain in a geriatric institutionalized sample. Pain 61, 271–276 (1995). Schofield PA, Clarke A, Faulkner M, Ryan T, Dunham M, Howarth A: An Annotated Bibliography for the Management of Pain in the Older Adult. University of Sheffield, UK (2005).
future science group
8
9
we try to narrow it down, for example do we include transcutaneous electrical nerve stimulation, spinal cord stimulators and cognitive behavioral therapy? In summary, working with older adults to manage their pain can be challenging for both the healthcare professional and the older adult themselves. Nevertheless, it can also be rewarding. Similarly, determining self-management strategies can also be problematic owing to the current confusion over definitions. However, working with older adults to explore the literature and identify an evidence base for their own self-management strategies can be a productive way forward to help clarify the issues. Financial & competing interests disclosure
Editorial
“…working with older
adults to explore the literature and identify an evidence base for their own self-management strategies can be a productive way forward to help clarify the issues.”
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript. Klinger L, Spaulding SJ, Polatajko HJ, MacKinnon JR, Miller L: Chronic pain in the elderly: occupational adaptation as a means of coping with osteoarthritis of the hip and/or knee. Clin. J. Pain 15(4), 275–283 (1999). Blomqvist K, Edberg A: Living with persistent pain: experiences of older people receiving home care. J. Adv. Nurs. 40(3), 297–306 (2002). Millen N, Walker C: Overcoming the stigma of chronic illness: strategies for normalisation of a ‘spoiled identity. Health Sociology Rev. 10(2), 89 (2010).
10
Lansbury G: Chronic pain management: a qualitative study of elderly people’s preferred coping strategies and barriers to management. Disabil. Rehabil. 22(1), 2–14 (2000).
11
Ersek M, Turner JA, Cane K, Kemp C: Chronic pain self management for older adults – a randomized controlled trial. BMC Geriatrics 4, 7 (2004).
12 Austrian JS, Kerns RD, Reid MC:
Perceived barriers to trying self-management approaches for chronic pain in older persons. J. Am. Geriatr. Soc. 53, 856–861 (2005).
13 Blyth FM, March LM, Nicholas MK,
Cousins MJ: Self-management of chronic pain: a population-based study. Pain 113, 285–292 (2005). 14
Ong BN, Hooper H: Involving users in low back pain research. Health Expect. 6(4), 332–341 (2003).
15
Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J: Self-management approaches for people with choric conditions: a review. Patient Educ. Couns. 48(2), 177–187 (2002).
16
Hadjistavropoulos T: The self-management of pain in older persons: helping people help themselves. Proceedings of the World Pain Congress (IASP). Montreal, Canada, 29 August–2 September (2010).
Website
101 The PIRICOM Study: a systematic review of
the conceptualisation, measurement, impact and outcomes of patients and public involvement in health and social care research. UKCRC http://bit.ly/bXfpQw (Accessed 18th October 2010)
www.futuremedicine.com
13
For reprint orders, please contact: [email protected]
Working with older adults to manage pain
Pat Schofield†
“Instead of proposing pain-management strategies based upon guidelines and experience, we need to listen to what the older adults are using themselves and provide them with the skills to identify evidence of efficacy and where this does not exist to develop ways of evaluating such approaches themselves.”
The population is aging; it is anticipated that the age distribution over 65 years will rise to 36% by 2050 and with the potential to live longer it has been suggested that we will see the over 80-year age group triple in numbers. With the frequency of pain being reported to be as high as 73% amongst community-dwelling older adults, and this figure increasing to 80% for those living in care homes, there is the potential for an aging pain ‘time bomb’ in the next three decades. This does not just relate to chronic pain; studies also demonstrate that acute pain is also poorly managed in this group [1] . Furthermore, 67% of cancer deaths occur in those over the age of 65 years and with cancer often comes pain [2] . There has been some discussion as to whether or not there is evidence of physio logical changes within pain processing attributable to age [3] . Certainly, there is some evidence that chronic pain is more prevalent in older adults along with some suggestion that altered physiology of peripheral and central pain mechanisms combined with psychological attitudes such as stoicism and reluctance to confirm
the presence of pain are all key factors [3] . Some take the perspective that pain is present in the same format irrespective of age [4] . So it may be that we need to consider the psycho–socio–cultural factors in the management of any individual experiencing pain, regardless of their age, and this approach requires a multidimensional perspective. However, we should not assume that getting older will increase the risk of being in pain or reduce the ability to cope with pain, as we have world leaders who are still active and important members of society whilst in their 80s. By contrast, others in this age group may be frail and suffering, thus suggesting that there is no uniform process in aging and pain. Poorly relieved pain is an important cause of functional impairment in any age group. With this we see reduced mobility, decreased socialization, sleep disturbance, slow rehabilitation and consequently increased healthcare utilization and costs. However, with older adults, such impact also precipitates social isolation that can lead to increased symptoms, such as depression and increased cognitive impairment [5] . A recent review of the literature
“The population is aging; it is
anticipated that the age distribution over 65 years will rise to 36% by 2050…”
Centre for Advanced Studies in Nursing (CASN), Centre of Academic Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen, AB25 2AY, UK Tel.: +44 122 455 4854; Fax: +44 122 455 0683; [email protected] †
10.2217/PMT.10.8 © 2011 Future Medicine Ltd
Pain Manage. (2011) 1(1), 11–13
ISSN 1758-1869
11
Editorial Schofield
“With the frequency of
pain being reported to be as high as 73% amongst communitydwelling older adults, and this figure increasing to 80% for those living in care homes, there is the potential for an aging pain ‘time bomb’ in the next three decades.…”
12
on the experiences of chronic pain in older adults highlighted a number of key issues [6] . For example, the main focus was on the effects of chronic pain on people’s daily lives and their ways of adjusting and coping with chronic pain within the community environment. Klinger et al. found that older people in the community adapted nearly half of their daily activities when experiencing pain, whilst less important tasks would be stopped altogether [7] . Other studies indicate that older people do not consider their pain to be a great problem; it was the effect pain had on their daily lives that seemed most problematic [8] . Furthermore, the qualitative literature suggests that older people link aging to physical decline and being in pain, and therefore they may be reluctant to seek help. This has also been found in the nursing home setting where, because older people believed their pain to be intractable, they often did not complain to staff [6] . Some authors describe a process of normalization where older women learn to ‘get on with it’ and develop their own management strategies [9] . Methods of coping identified include: spending time with family and friends, and diversional activities, such as reading and watching the television. Rest and other interventions such as heat or ‘folk’ remedies are cited as being used, with medication only taken as a last resort [7,10] . One author found that older people preferred self-administered strategies for managing their pain (e.g., massage and informal cognitive coping strategies) [11] . Traditional methods such as medication, physiotherapy and exercise were least preferred [10] . It was also noted that older people appreciate being actively involved in the management of their pain, presumably because this provides them with a sense of control. Older adults seldom use approaches to manage their pain that are perceived to be helpful in the younger population, for example relaxation, muscle relaxation and imagery. However, it has been suggested that there are a wide variety of barriers to effective management of pain within this population and these are associated with the healthcare system or professionals. Furthermore, further barriers have been cited as existing amongst the older adults themselves. For example, one study has identified barriers such as fear of falling and restrictions due to disability associated with failure to participate in exercise. A further more focused study by Austrian et al. identified 17 barriers to participation in painmanagement programs, which they grouped into
Pain Manage. (2011) 1(1)
three main categories: access, internal attribution and program-specific issues [12] . They suggested that some of the barriers identified were linked to the individual having a ‘lack of control over one’s life’. They did acknowledge that there were some limitations in this study but suggested future work needed to look at how to engage older adults in the pain-management process. Further studies have shown that self-management strategies are associated with better coping, and lower levels of pain-related disability and healthcare use [13] . So how can we engage with older adults to enable this process of improved self-management of pain? One perspective may be to enable a sense of control, as research suggests that older people are more concerned with well-being, prevention of illness and quality of life. This would suggest working with older adults to manage pain as opposed to managing their pain for them. But in order to do this we need to determine what strategies for pain management are preferred by them and subsequently establish the evidence underpinning such approaches. This requires a change in perspective on the part of the healthcare professionals. Instead of proposing pain-management strategies based upon guidelines and experience, we need to listen to what the older adults are using themselves and provide them with the skills to identify evidence of efficacy and where this does not exist, to develop ways of evaluating such approaches themselves. This is work that is ongoing within Aberdeen. This means ‘involving service users’ more actively and collaboratively. The patient, public involvement (PPI) movement is growing and developing fast, and we are seeing more and more emphasis on involving service users not only in advising on research projects, but helping to develop them and identifying priority areas. Thus, it would be reasonable to enlist the help of older adults and ask them to identify what is important for them and how they feel their pain should be managed, and enable them to access the evidence and determine what further research needs to be done, which is what we have been doing for the past 2 years. Two issues arise from this approach that must be acknowledged. First, whilst a recent systematic review on the use of PPI [101] does identify some beneficial impacts of PPI, it also identifies some negative impacts, including those upon policymakers, researchers and the participants themselves. Costs, training, time and difficulties with publishing have all been listed as challenges with this approach [101] .
future science group
Working with older adults to manage pain Furthermore, participants themselves can find it challenging as they can feel that they are not listened to or become frustrated that researchers assume they have no knowledge [14] . Often such an emphasis has led to the ‘lip service’ approach to PPI where service users are invited to sit on advisory boards but their opinions not considered important or given the time to be heard. A second challenge with involving older adults in managing their own pain is more fundamental within the pain world itself and relates to the definition of self-management, which appears to be causing some controversy. Management of many chronic illnesses require that the individual or their carer takes extensive responsibility for their own management and as suggested by Barlow et al. [15] , self-management needs to enable the individual to “monitor their own condition and the impact that it may have upon quality of life”. A recent review of the literature identified 63 studies for a range of chronic illnesses including chronic pain-related conditions. The term self-management has been used loosely to describe a variety of programs where the patient plays an active role in the treatment program [16] . However, a dilemma exists when Bibliography 1
2
3
4
5
6
7
Desbiens NA, Mueller-Rizner N, Connors AF: Pain in the oldest old during hospitalisation and up to one year later. J. Am. Soc. Geriatr. Dent. 45, 1167–1172 (1997). D’Agostino NS, Gray G, Scanlon C: Cancer in the older adult: understanding age related changes. J. Gerontol. Nurs. 16, 12–15 (1990). Gibson SJ, Weiner D (Eds). Pain in Older Persons, Progress in Pain Research and Management. IASP Press, Seattle, WA, USA, 35, 67–85 (2005). Sorkin BA, Rudy TE, Hanlon RB, Turk DC, Stieg RL: Chronic pain in old and young patients: differences appear less important than similarities. J. Gerontol. 45(2), 64–68 (1990). Casten RJ, Parmelee PA, Kleban MH, Lawton MP, Katz IR: The relationships among anxiety, depression, and pain in a geriatric institutionalized sample. Pain 61, 271–276 (1995). Schofield PA, Clarke A, Faulkner M, Ryan T, Dunham M, Howarth A: An Annotated Bibliography for the Management of Pain in the Older Adult. University of Sheffield, UK (2005).
future science group
8
9
we try to narrow it down, for example do we include transcutaneous electrical nerve stimulation, spinal cord stimulators and cognitive behavioral therapy? In summary, working with older adults to manage their pain can be challenging for both the healthcare professional and the older adult themselves. Nevertheless, it can also be rewarding. Similarly, determining self-management strategies can also be problematic owing to the current confusion over definitions. However, working with older adults to explore the literature and identify an evidence base for their own self-management strategies can be a productive way forward to help clarify the issues. Financial & competing interests disclosure
Editorial
“…working with older
adults to explore the literature and identify an evidence base for their own self-management strategies can be a productive way forward to help clarify the issues.”
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript. Klinger L, Spaulding SJ, Polatajko HJ, MacKinnon JR, Miller L: Chronic pain in the elderly: occupational adaptation as a means of coping with osteoarthritis of the hip and/or knee. Clin. J. Pain 15(4), 275–283 (1999). Blomqvist K, Edberg A: Living with persistent pain: experiences of older people receiving home care. J. Adv. Nurs. 40(3), 297–306 (2002). Millen N, Walker C: Overcoming the stigma of chronic illness: strategies for normalisation of a ‘spoiled identity. Health Sociology Rev. 10(2), 89 (2010).
10
Lansbury G: Chronic pain management: a qualitative study of elderly people’s preferred coping strategies and barriers to management. Disabil. Rehabil. 22(1), 2–14 (2000).
11
Ersek M, Turner JA, Cane K, Kemp C: Chronic pain self management for older adults – a randomized controlled trial. BMC Geriatrics 4, 7 (2004).
12 Austrian JS, Kerns RD, Reid MC:
Perceived barriers to trying self-management approaches for chronic pain in older persons. J. Am. Geriatr. Soc. 53, 856–861 (2005).
13 Blyth FM, March LM, Nicholas MK,
Cousins MJ: Self-management of chronic pain: a population-based study. Pain 113, 285–292 (2005). 14
Ong BN, Hooper H: Involving users in low back pain research. Health Expect. 6(4), 332–341 (2003).
15
Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J: Self-management approaches for people with choric conditions: a review. Patient Educ. Couns. 48(2), 177–187 (2002).
16
Hadjistavropoulos T: The self-management of pain in older persons: helping people help themselves. Proceedings of the World Pain Congress (IASP). Montreal, Canada, 29 August–2 September (2010).
Website
101 The PIRICOM Study: a systematic review of
the conceptualisation, measurement, impact and outcomes of patients and public involvement in health and social care research. UKCRC http://bit.ly/bXfpQw (Accessed 18th October 2010)
www.futuremedicine.com
13
