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Special Issues in the Management of Chronic Pain in Older Adults

Patricia Bruckenthal PhD, RN, ANP, M. Carrington Reid MD, PhD, Lori Reisner PharmD
DOI: http://dx.doi.org/10.1111/j.1526-4637.2009.00667.x S67-S78 First published online: 1 July 2009

ABSTRACT

Pain syndromes are prevalent among older individuals and generally increase in incidence as the population ages. Yet, pain often is undertreated in older patients, sometimes due to difficulties in assessing pain intensity and the effectiveness of treatment in the context of age-related cognitive impairment and physiologic changes. As a result, older patients with chronic pain conditions are more likely to experience greater functional limitations and decreased quality of life due to these and other barriers to appropriate care. This article discusses the epidemiology, assessment, and management of pain in older adults, and reviews special issues in the treatment of this population, such as adverse effects due to changes in drug metabolism and drug–drug interactions.

  • Adults
  • Chronic
  • Older
  • Opioids
  • Pain

Epidemiology of Chronic Pain Syndromes in Older Individuals

Modern advances in public health, preventive care, and medical treatments have led to increases in average life span of persons in industrialized countries [1]. Unfortunately, the full impact of these advances is undercut by a corresponding increase in the incidence of age-related diseases, including cardiovascular disorders, diabetes, cancer, osteoporosis, and degenerative joint disease. The degree of pain that accompanies most of these diseases is not completely understood. One community-based report found that 35.7% of adults in the United States aged 60–69 years reported experiencing pain throughout the day, with 16.5% experiencing episodes of pain with a rating of 3 or more on a 0–6 scale [2]. That percentage was similar for 70- to 89-year-olds, but jumped to 56.1% in adults aged 90–99 years [2]. Another study conducted in Ontario, Canada, found that 48% of adults aged 65 years and older experienced pain daily [3].

Other epidemiologic research indicates that pain is highly prevalent in older populations [4]. For example, Lawrence and colleagues reported that osteoarthritis (OA) of at least one joint was present in 12.1% of adults aged 25–74 years, with the incidence increasing with age [5]. Symptomatic OA of the hand (defined as frequently painful and showing radiologic degeneration) was present in 26% of women and 13% of men older than 71 years of age compared with a prevalence of less than 7% in all adults ≥26 years of age; symptomatic OA of the knee was present in 16.7% of adults older than 45 years, compared with 4.9% of adults older than 25 years [5].

Back pain is highly prevalent among older persons [6], with prevalence estimates ranging from 13% to 49% among those aged 65 or older [7]. Severity of pain was not measured in these studies, but in one, the pain was characterized as mainly intermittent [6,7]. Other researchers have reported that 22% of adults between the ages of 68 years and 100 years experience back pain “on most days”[8], and that back pain is considered one of the most important factors affecting individual health status in those older than age 65 [9].

Vertebral compression fractures and osteoporosis are the result of bone demineralization and are a well-documented phenomenon of aging, particularly in postmenopausal women [10]. Loss of bone mineral density can also predispose patients to traumatic long-bone fractures [11]. The lifetime risk for fracture resulting from osteoporosis in women older than 50 years has been estimated at 54% [12]. In some cases, age-associated deficiencies in vitamin D can predict development of osteoporosis, osteoarthritis, and secondary pain complications [13]. In a recent study, vitamin D deficiency was associated with a significantly higher prevalence of moderate chronic back pain in women (odds ratio, 1.96; 95% confidence interval [CI] 1.01–3.59) but not in men [13].

Other noncancer-related pain syndromes, such as postherpetic neuralgia (PHN) and painful diabetic neuropathy (PDN), are also common in older individuals. PDN affects approximately 15% of patients with diabetes [14], a figure that is especially important given that the prevalence of diabetes increases rapidly with advancing age [15]. Increased age also is associated with a higher prevalence of PHN. One study of patients in a health maintenance organization showed that those aged 50 years and older had a 15-fold higher incidence of developing PHN than their younger counterparts [16]. A different study indicated that 12.5% of persons older than age 60 who develop acute herpes zoster will develop PHN [17]. Although the true incidence is difficult to measure because of differences in reporting, data consistently show that the incidence of PHN increases with age [18].

The deleterious consequences of inadequately treated pain are far reaching and include impaired quality of life (QoL) and sleep, as well as decreased immune function, cognition, and mobility [19]. One of the most dreaded and common consequences of persistent pain in older populations is loss of functional independence [20,21]. Indeed, pain is by far the most frequently cited symptom causing activity of daily living disability in later life [22].

The physical and emotional distress that occurs as a consequence of pain often undermines an individual's confidence in their health. For example, the presence of daily pain was found to be a stronger predictor of low self-rated health than either advancing age or number of chronic diseases in a recent study of 6,500 U.S. adults [23].

Despite their high prevalence and significant impact on QoL, pain syndromes are often undertreated in older patients [24]. Provider-level reasons for undertreatment include a lack of screening and identification [24], lack of education/training in treating pain, and the belief that pain is an expected part of the aging process, whereas patient-level reasons include underreporting, cognitive impairment, and the belief that pain is a part of the aging process [25].

Special Considerations in the Assessment of Pain in the Older Population

Assessing older individuals for pain requires special attention [25]. A variety of common pain scales can be used, including the visual analog scale, numerical rating scale, and pain thermometer (Figure 1) [26,27]. It is important to recognize, however, that older patients may express pain differently from younger patients; for example, they may complain of “discomfort” or “aches” instead of “pain.” Clinicians should recognize these descriptors as potential indicators of pain and clarify with further questioning.

Figure 1

Pain thermometer. Source: adapted from AGS Panel on Chronic Pain in Older Persons [25].

The ability to communicate pain symptoms may be particularly limited in patients with cognitive impairment (Table 1) [25]. Morrison and Siu studied patients with hip fractures and observed that those with dementia received one-third fewer analgesics than those with intact cognition, likely demonstrating that patients with dementia did not receive adequate medication for their pain [28].

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Table 1

Common pain behaviors in cognitively impaired older patients

Body movementsChanges in gait, mobility
Fidgeting
Increased pacing, rocking
Restricted movement
Rigid, tense body posture; guarding
Changes in activity patterns or routinesChanges in sleep, rest patterns
Increased rest periods
Increased wandering
Refusal of food; appetite change
Sudden cessation of common routines
Changes in interpersonal interactionsAggression, combativeness, resistance to care
Decreased social interactions
Inappropriate, disruptive social interactions
Withdrawal
Facial expressionsDistorted expression
Grimacing, wrinkled forehead, closed or tightened eyes
Rapid blinking
Slight frown; sad, frightened face
Mental status changesCrying or tears
Increased confusion
Irritability or distress
Verbalizations, vocalizationsAsking for help
Grunting, chanting, calling out
Noisy breathing
Sighing, moaning, groaning
Verbally abusive

Multiple tools are available to assess pain in older adults with cognitive impairment and limited verbal ability (Table 2). More detailed reviews provide information on psychometric property testing and the ease of use of these instruments [29–33]. For example, the Noncommunicative Patient's Pain Assessment Instrument (NOPPAIN) rates specific pain-related behaviors during common care tasks. Another nonverbal scale, Pain Assessment in Advanced Dementia (PAINAD), rates breathing, negative vocalization, facial expression, body language, and consolability. The Pain Assessment for the Dementing Elderly (PADE) is a 24-item tool that rates physical, global, and functional variables. Many investigations have concluded that these measures provide valid and accurate assessments of pain across a range of older adults with varying cognitive abilities [30–33]. Such scales are tools that should be used as a component of pain assessment for patients who cannot report their own symptoms. These tools should be used in conjunction with a careful and complete history and physical examination, with particular attention to musculoskeletal and neurologic components [4,29].

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Table 2

Common behavioral/nonverbal pain assessment tools [32]

NameSectionsItems ScoredDescription
Noncommunicative Patient's Pain Assessment Instrument (NOPAIN)4 sectionsObserved daily activities such as words, pain faces, noises, rubbing, restlessnessBrief, but scoring interpretation not available
Pain Assessment in Advanced Dementia (PAINAD)5 itemsBreathing, negative vocalization, facial expression, body language, consolabilityModified pain scales by category, short and manageable
Pain Assessment for the Dementing Elderly (PADE)24 itemsIncludes facial expressions, global pain, and functional activitiesNewly developed for the dementing elderly, but difficult because of scoring multiple components

Treatment Modalities in Older Patients

Pharmacologic Therapies

Acetaminophen (APAP) and nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most common analgesics used to treat mild to moderate pain conditions. Effective for pain of nociceptive origin and widely available in over-the-counter (OTC) formulations, these agents have important adverse effects that may not be known to laypersons or understood by older adults with or without cognitive impairment [34]. For example, NSAIDs are known to produce ulcerations of the gastric mucosa and adversely affect renal function in a dose-dependent manner [35–37]. Prolonged NSAID exposure also increases gastrointestinal (GI) risks. These risks may be pronounced in older individuals; investigators have reported that the risk for NSAID-induced upper GI tract bleeding/perforation increases 20-fold in adults aged 75 or older [36]. The class of selective cyclooxygenase (COX)-2 inhibitor NSAIDs has been linked to an increased incidence of acute coronary syndrome, although there is evidence that cardiovascular-related adverse events are not limited to the selective COX-2 inhibitors [35,38]. Thus, the risks and benefits of NSAIDs should be weighed carefully in older patients, who typically already possess one or more risk factors for cardiovascular disease. Concomitant use of a proton pump inhibiting agent may be gastroprotective, but only for the upper GI tract [39].

Although APAP has a small adverse effect profile when used in appropriate doses, older patients with cognitive impairment who manage their own medications may be prone to unintentional overdose, particularly because APAP is available without prescription. Patients also may inadvertently exceed the recommended daily dose if they take nonprescription formulations of APAP in addition to a prescription formulation that includes the drug, such as APAP/oxycodone or APAP/hydrocodone. Larson and colleagues studied 275 cases of APAP-induced liver injury occurring at 22 tertiary care centers in the United States and determined that chronic pain and concomitant ingestion of different preparations containing APAP significantly increased the risk for APAP-induced liver failure [40]. A survey of inpatients' drug knowledge showed that 66–90% of participants did not know which of several medicines contained APAP, and only 7% knew the maximum daily dose [34]. These data suggest that close oversight of pain medication use is necessary in older patients, particularly those with cognitive impairment [41]. In particular, the use of fixed-dose combinations of analgesic agents, such as those that combine APAP with an opioid (e.g., APAP/oxycodone; APAP/hydrocodone), may raise the risk of exceeding the recommended maximum daily APAP dose (4 g/day for acute use or 2.6 g/day for chronic use), which could lead to inadvertent APAP overdose, either because patients are instructed to increase their dose as needed or because patients may self-administer additional APAP along with these combination agents.

Finally, chronic use of either APAP or NSAIDs has been linked to elevations in blood pressure [42]. Because hypertension is quite prevalent among older populations and is linked to significant morbidity and mortality, substitution of other analgesics for APAP and NSAIDs warrant consideration in patients who experience refractory elevations in blood pressure during ongoing use of these agents [43].

When pain becomes moderate to severe or patients experience functional impairment or diminished QoL as a result of pain, a trial of an opioid or tramadol is indicated. These medications should be prescribed on a trial basis with clearly defined therapeutic goals and should only occur after a thorough discussion between the patient and provider has occurred, where the relative risks and benefits associated with treatment have been carefully reviewed [19]. The trial may involve serial attempts to titrate the medication to an effective dose without intolerable side effects. Specific recommendations for treatment in older populations include lower doses (due to age-related decreases in creatinine clearance) and slower titration to reduce onset of adverse events [44,45]. Some investigators have suggested that establishing baseline pain control with a long-acting opioid (LAO) in older populations produces superior outcomes compared with as-needed use of short-acting opioids (SAOs). For example, Won and colleagues performed a longitudinal study of 10,372 nursing home residents with chronic pain and reported improvement in functional status (adjusted hazard ratio [HR], 1.85; 95% CI 1.05–3.23) and social engagement (adjusted HR, 1.58; 95% CI 0.99–2.50) with LAOs relative to SAOs [46]. Although no data support the efficacy of LAOs over SAOs in the general population, LAOs have been linked to improved QoL ratings in patients with cancer [47,48]. Provisions such as less frequent dosing and around-the-clock medication can be helpful to both patient and their caregivers, particularly in the setting of comorbid conditions, including frank dementia or cognitive dysfunction. Use of scheduled doses of LAOs can also decrease the total pill burden for older adults, and thus promote medication adherence through simplified regimens [49]. Finally, patients taking opioid analgesics should be reassessed for ongoing attainment of therapeutic goals, adverse effects, and safe and responsible medication use [19].

Special care must be taken to monitor for opioid-related adverse effects, such as sedation, confusion, and constipation, which may be more pronounced in older patients, particularly in those with cognitive impairment [19,44]. A routine bowel monitoring and treatment regimen is recommended for patients on long-term opioid therapy [44]. This should include a daily stool softener and a stimulant laxative. It has been suggested that aggressive once-daily loading doses (administering twice the intended daily dose to rapidly achieve steady-state plasma drug levels) may not be appropriate in older or opioid-naïve patients because of increases in rates of adverse events [50].

Benzodiazepines have also been used in the treatment of a variety of painful conditions, particularly muscle spasms, neuropathic pain, or to alleviate anxiety related to pain crises. These agents have wide therapeutic margins in the general population but should not be used in older adults due to prolonged elimination, symptomatic rebound, dizziness, increased fall risk, and increased cognitive or affective effects [51–53].

Antidepressants may be useful in older patients with pain syndromes and may act either by modulating pain through direct pathophysiologic mechanisms or by treating underlying depression that may otherwise augment perception of pain and lead to a decrease in the use of positive coping skills [54]. An analysis of numbers needed to treat derived from clinical trial data showed that tricyclic antidepressants are effective for treating neuropathic pain when compared with selective serotonin reuptake inhibitors (SSRIs), gabapentin, dextromethorphan, tramadol, levodopa, and capsaicin [55]. However, tertiary amines (e.g., amitriptyline, imipramine, trimipramine, doxepin, clomipramine, lofepramine [not FDA approved or not marketed in the U.S.]) should be avoided in older patients because of greater anticholinergic side effects, including sedation, delirium, urinary retention, constipation, glaucoma exacerbation, and dizziness and, for amitriptyline, especially, the risk of cardiac arrhythmia [53,56]. By contrast, secondary amines (nortriptyline, desipramine, protriptyline, amoxapine) tend to have better adverse event profiles in older patients [53,56]. Serotonin norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (U.S. Food and Drug Administration approved for diabetic peripheral neuropathic pain, fibromyalgia, major depressive disorder, and generalized anxiety disorder) [57] and venlafaxine can provide analgesic relief at low doses (<150 mg/day). Conversely, SSRIs such as fluoxetine and sertraline do not appear to be effective for pain management like the SNRIs, and some reports suggest that SSRIs when combined with NSAIDs or medications affecting bleeding/coagulation further increase risk of GI bleeding [56,58]. Although SSRIs as a class have the least evidence for clinical efficacy, some clinicians may choose to prescribe them based on their relatively safe adverse effect profile [59]. However, fluoxetine and paroxetine, like duloxetine, carry the potential for many significant drug–drug interactions; this should be considered when prescribing them to older adults who may already be taking several medications for chronic disease management [59].

Some anticonvulsants have been indicated or used off-label for neuropathic pain and sleep disturbances [56]. In older patients, certain second-generation anticonvulsants such as gabapentin and pregabalin may have a more favorable adverse event profile compared with first-generation anticonvulsants [56], and may be associated with fewer drug–drug interactions [53,56]. However, these drugs may exacerbate gait or cognitive impairment, effects that may be somewhat ameliorated by bedtime dosing [60].

Topical Therapies

Topical medications are gaining increasing popularity in the United States and abroad, and much of their appeal is based on a reduction of adverse drug reactions as well as fewer drug–drug interactions due to their limited systemic availability [61]. Several of these have been approved for pain management, including capsaicin cream, topical lidocaine patches for PHN, and diclofenac gel for OA [61–63]. A topical diclofenac epolamine (1.3%) patch [61] is available for the treatment of acute pain of minor strains and sprains. Each of these agents is applied directly to the area(s) of pain or discomfort for a prescribed period. Capsaicin, although effective, is not widely used due to the burning sensation it induces, the need for frequent application, and its esthetic inelegance (e.g., problems with clothing or occlusive dressings). The lidocaine patches can reduce painful neuropathic symptoms [61]. In contrast, repeated application of diclofenac gel or patches can produce measurable serum levels, but these are lower than those attained with oral preparations [63]. The most common side effect of all topical therapies is a local application site reaction (e.g., irritation or rash), due to the vehicle, the drug itself, or the adhesive [61]. Because of the benefits offered by this alternative route of drug delivery, other topical therapies are in development and present an attractive therapeutic option that reduces risk of drug-related events.

Nonpharmacologic Therapies

Nonpharmacologic modalities also can be useful in the treatment of diverse pain syndromes, either on their own or as adjuncts to pharmacotherapy. For example, physical therapy, transcutaneous electrical nerve stimulation, hypnosis, meditation, relaxation, guided imagery, biofeedback, prayer, and music therapy have all been found to reduce subjective pain complaints to varying degrees [64–66]. Although cognitive–behavioral therapy (CBT) has an established track record in reducing reported pain levels [67], some patients may havedifficulty accessing this treatment because of the small number of clinicians who provide it [67]. Low-impact exercise, such as walking, stationary bicycling, water aerobics, and tai chi, also may be helpful in reducing subjective pain complaints and improving functional status [68–70].

Self-efficacy and coping skills are important in pain management and can improve pain and functional outcomes [71,72]. Some older patients prefer home remedies, massage, topical agents, physical modalities (e.g., heat and cold), and informal cognitive strategies to the more commonly prescribed exercise, physical therapy, and medications [64]. Information distributed by medical societies and foundations (e.g., the Arthritis Foundation) in the form of pamphlets or online programs can be helpful in guiding self-help efforts [73], including some CBT techniques (Table 3). The “dose” of CBT interventions administered may vary widely; therefore, compliance with treatment, or the degree to which treatment is administered as intended, is an important part of optimizing outcomes for older patients with pain syndromes.

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Table 3

Resources for the treatment of chronic pain in older patients

ReferenceInternet Address
Books
  Persistent Pain in Older Adults; Debra K. Weiner et al.  http://www.amazon.com/Persistent-Older-Adults-DebraWeiner/dp/0826138357
  Managing Pain in the Older Adult; Michaelene P. Jansen, ed.  http://www.springerpub.com/prod.aspx?prod_id=15675
  Pain Management for Older Adults: A Self-Help Guide; Thomas Hadjistavropoulos et al.  http://www.iasp-pain.org/AM/Template.cfm?Section-home&content/0-8240&template-cm/contentdisplay.cfm
  Pain in Older Persons: Progress in Pain Research Management; Stephen J. Gibson et al., eds.  http://www.iasp-pain.org/
Guidelines
  AGS Guide on the Management of Persistent Pain in Older Persons  http://www.americangeriatrics.org/education/manage_pers_pain.shtml
  Persistent Pain Management  http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=8627&nbr=4807
Other resources
  The Arthritis Foundation  http://www.arthritis.org/am/template.cfm?section-home&contentid-8246&template-/cm/contentdisplay.cfm
  National Council On Aging's Center For Health Aging  http://www.healthyagingprograms.org
  National Council on Aging's National Institute of Senior Centers (NISE)  http://www.ncoa.org/content.cfm?sectionID=342
  National Institutes of Health Pain Consortium  http://painconsortium.nih.gov/
  Stanford University Patient Education Research Center  http://patienteducation.stanford.edu/programs/
  American Chronic Pain Association  http://www.theacpa.org
  American Pain Society  http://www.ampainsoc.org/
  American Medical Director's Association  http://www.amda.com
  The John A. Hartford Foundation  http://www.jhartfound.org
  The AGS Foundation for Health in Aging  http://www.healthinaging.org
  • AGS = American Geriatric Society.

Finally, condition-specific interventional therapies (e.g., decompressive laminectomy, kyphoplasty, joint replacement, epidural steroid injections, or nerve blocks) can relieve pain in some circumstances. Although elderly patients may have increased surgical risks, the decision to pursue an interventional strategy in a patient with pain should be based not on patient age but on the appropriateness of the intervention in treating the condition. Input from a specialist (e.g., neurosurgeon, orthopedist, anesthesiologist, pain specialist) may be helpful after a thorough analysis of the risks and benefits of the procedure, with special attention to any underlying comorbid conditions that may increase the risk for periprocedural complications.

Other Treatment Considerations in Older Patients

Several issues can complicate the treatment of older patients with pain (Table 4). In particular, adverse drug–drug interactions or age-related changes in drug metabolism are major considerations when formulating pain treatment regimens in older patients. Hanlon and colleagues examined 167 older patients taking at least five medications in a yearlong health service intervention trial. Adverse drug reactions were reported by 35% of patients, among whom 63% contacted a physician, 10% went to the emergency room, and 11% were hospitalized [74]. A second study (N = 106) found that severe adverse drug reactions were present in almost 1 out of 4 older patients in five university hospital wards [75].

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Table 4

Age-related considerations in the treatment of chronic pain

Effects of cognitive impairmentDecreased pain perception
Inability to describe pain symptoms
Inability to follow treatment regimens
Potential for inadvertent overdose
Increased risk of drug-related adverse effectsAltered drug pharmacodynamics and pharmacokinetics
Comorbid conditions
Improper use of medications due to cognitive impairment
Increased susceptibility to adverse effects (e.g., anticholinergic side effects)
Polypharmacy
Psychosocial factorsDepression
Economic constraints
Loss of independence
Loss of support systems
Patient expectations
VulnerabilityDrug diversion

Secondary Considerations with Pharmacotherapy

Age-related changes in drug metabolism arise from decreased renal and hepatic function, higher fat–lean muscle mass ratio, decreased serum protein levels, and other factors. As a result, drug-related adverse effects may occur in older patients at doses much lower than would be observed in younger patients [76]. To compensate for this phenomenon, lower starting doses, slower titration, and lower maximal drug dosing may be indicated in older patients. The use of lower doses of two synergistic agents may reduce dose-related adverse effects while preserving the analgesic efficacy of the treatment regimen, provided that important adverse drug–drug interactions are avoided [77]. As an added complication, treatment compliance generally decreases with age and pill burden, making stable blood levels of pharmaceuticals and predictable pharmacokinetics less likely [78].

Clinicians also should be cognizant that many patients combine their prescribed medications with herbal supplements, vitamins, and other OTC products to augment pain control or for unrelated reasons [79]. Some of these agents may have harmful interactions. For example, St. John's wort is often used to treat the anxiety, depression, and sleep disorders that can accompany pain syndromes. Although clinical data are limited, this herbal product interacts with many medications, including methadone and other drugs metabolized by the cytochrome (CYP) P450 pathway [80]. Other common herbals, such as feverfew, may potentiate the effects of anti-inflammatory agents (e.g., NSAIDs) and/or bleeding when used with antiplatelet agents [81]. All patients on chronic pain medications should therefore be asked about their use of nonprescription or herbal remedies.

The CYP system, which metabolizes opioids and other medications often used in the management of pain, is an important factor in several pharmacokinetic drug interactions. Two or more drugs sharing a common metabolic pathway can result in enhanced drug toxicity, altered pharmacologic effects, or adverse drug reactions [44]. In particular, 2A and 2C isoenzyme activity can decrease with advancing age, and these are important metabolic pathways for APAP, some anticonvulsants, and cardiovascular agents [82]. For elderly individuals, the high prevalence of age-related comorbid conditions (e.g., cardiovascular disease, diabetes, insomnia) requiring medical treatment can lead to polypharmacy [83], including the prescription of medications that can alter CYP activity or interact with pain medications through mechanisms independent of the CYP pathway. A national survey of noninstitutionalized American adults found that more than 40% of patients aged 65 years or older take five or more different drugs (prescription, nonprescription, and herbals/supplements) per week, and 12% take 10 or more medications—the number drops by half (approximately 20% of patients aged 65 years or older take five or more different drugs) when counting only prescription medications [84]. In some cases, multiple medications may be prescribed by several different practitioners, who may be unaware of the patient's complete medication profile. Such fragmentation of patient care (spread across multiple specialists) can raise the risk for prescription of inappropriate medications. Methodical examination of the patient's medication profile and good communication between members of the care team are essential to avoid preventable errors when initiating or modifying pain treatment regimens.

Appropriate Medication Choice

Consensus criteria for selecting safe medications for use in older adult patients have been investigated. The most widely used consensus criteria for medication use in older adults are the Beers criteria, originally adopted by the Centers for Medicare and Medicaid Services in July 1999 for nursing home regulation. The criteria were updated in 2003 by nationally recognized experts in geriatric care, clinical pharmacology, andpsychopharmacology using a modified Delphi technique and an extensive literature review. The updated criteria specify 48 individual or classes of medication to be explicitly avoided in older patients, as well as specific treatment indications for 20 disease states in these patients [85].

Nevertheless, drug errors still occur. Using the Beers criteria, Lau and colleagues found that 50% of nursing home residents aged 65 years or older received at least one potentially inappropriate prescription [86]—inappropriate drug choice, excess dosage, or potential drug–disease interaction [87,88]—during a 6-month period. Budnitz and colleagues reviewed an estimated 177,504 emergency department visits among U.S. patients aged 65 years or older for adverse drug events (N = 4,492) and reported that an estimated 3.6% of these visits were for adverse events related to medications considered always potentially inappropriate under the Beers criteria. One-third of the visits were attributed to adverse effects of warfarin, insulin, and digoxin, only the last of which is included on the Beers list [89]. Various studies have shown that consideration of the Beers criteria when constructing medical treatment regimens reduces drug-related adverse effects in older adults, although, clearly, it is only a starting point for determining appropriate pharmaceutical selection [90–92].

Sociological Issues

Nonmedical issues play a particularly important role in achieving adequate control of pain in older patients. For example, many patients are on fixed incomes and may not be able to afford newer, more expensive agents. Other patients may believe that pain is a normal part of aging and may not pursue effective treatments for their symptoms [4]. In, still, other cases, cognitive impairment may interfere with a patient's ability to understand or carry out the proper use of a prescribed regimen [93]. The provision of visual aids and printed educational material may help ensure proper use of medications in patients with mild cognitive impairment [94].

As is true of any context in which controlled substances are dispensed, the misuse, abuse, and diversion of prescribed medications remain concerns in the care of chronic pain. Drug diversion may be particularly problematic among older patients, who frequently require assistance from others to manage their medications. In one analysis, diversion of prescribed medications from friends or family accounted for the drug source in 70% of cases of illicit prescription medication use [95]. Additionally, drug abuse by older adults has increased over the last 7 years in the 50–54 year and 54–59 year age groups, suggesting that as the “baby-boomer” cohort moves into these age groups, they have continued their higher lifetime rates of illicit drug use relative to older cohorts [95].

Although some investigators have reported that age greater than 50 years is a significant risk factor for drug abuse, others have found that advanced age is associated with a decreased risk for abuse. Although the relative risk for drug abuse in older patients undergoing treatment for chronic pain has not been well characterized, it is important to note that roughly 25% of older adults take psychoactive substances with abuse potential [96–98]. As with any population, screening for drug misuse, abuse, and diversion is an essential component of the management of patients receiving psychoactive medications for pain, irrespective of patient age. In the older adult population, urine drug testing can serve to mitigate risk and measure compliance with therapy, which can also be a concern among patients uncomfortable with taking potent analgesics.

Finally, psychosocial difficulties can exacerbate the experience of pain. Older individuals are at greater risk for experiencing psychosocial stressors, including loss of independence, functional decline, social isolation, and loss of a spouse or friends. Thus, a multidisciplinary approach that addresses medical as well as psychosocial needs is required to achieve optimal outcomes in older patients with chronic pain.

Conclusion

Pain is becoming an increasingly prevalent clinical challenge to physicians as the proportion of older adults grows. The assessment, treatment, and management of older patients with chronic pain require special consideration. Assessment can be particularly challenging in elderly patients with diminished cognitive ability. Similarly, physician and patient biases about appropriate pain treatment—particularly the use of opioids—may also confound adequate care. In addition, older patients are more likely than their younger cohorts to have multiple comorbidities and to be taking multiple medications, two factors that can interfere with successful treatment. Finally, physiologic and sociologic changes associated with aging can interfere with the ability of the physician to manage a patient with chronic pain, as well as that patient's ability to comply with the prescribed treatment regimen. Like any special population, continuing pain management in older adults requires the physician to apply specialized knowledge and care with treatment, and to consider how this population differs from other groups of patients living with chronic pain.

Disclosures

Dr. Reid has no disclosures to report.

Dr. Bruckenthal has received funding to present from unrestricted educational grants from Endo, Abbott, and King Pharmaceutical.

Dr. Reisner did not report any disclosures.

This supplement has been sponsored by an unrestricted grant from King Pharmaceuticals®, Inc. Editorial support was provided by Megan Fink, Ariel Buda-Levin MS, John Lapolla MS, Maggie Van Doren PhD, Jim Kappler PhD, as well as Innovex Medical Communications.

References

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