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Pain Management and the Older Adult
Katherine Kidder Waldman, OTR, MBA

The fastest growing segment of the U.S. population is the elderly, which is defined as being over 65 years of age. Management of their pain requires special attention to cognitive impairment, physiological changes, concurrent disease processes, and cultural issues. Pain in this population is often unrecognized and under treated. Untreated pain places individual for risk of additional health problems (McCaffery & Pasero, 2001). Awareness of the added complication of diagnosis and treating pain problems in the older adult will increase the effectiveness of the pain management specialist.

Many aging patients have multiple medical problems making it difficult to determine the source of the pain problem (Todd, 2001). It is extremely important to obtain a thorough physical exam and to reassess the patient for health related changes with each visit. It is a common for the pain practioner to only evaluate the area of reported pain and to overlook the other systems that could be contributing to or exacerbating the condition.

Alzheimer’s disease, dementia, stroke, diabetes, and cardiovascular disease are a few of the common health problems that contribute to the cognitive impairment of the elderly patient. Memory loss and confusion make accurate pain assessment a challenge. If assessment is difficult, care givers should be interviewed to obtain a complete pain picture. Many patients with cognitive impairment are still able to accurately respond to a 10 point pain scale. Appropriate pain relief in this population is essential as pain control can aid in decreasing mental confusion.

Physiological changes that occur with aging may adversely affect drug sensitivity and interfere with adequate pain control. With aging, there is some loss in nerve cells or their dendrite connections, but there is no change in sensitivity to pain. (Todd, 2001) In addition, the aging adult may experience the changes listed in Table 1.

      Table 1 Physiologic Changes in the older patient

      ·1 An increase in connective tissue that affects cardiovascular and musculoskeletal tissue

      ·2 A decrease in metabolic rate

      ·3 A decrease in hepatic efficiency and blood flow

      ·4 A decrease in kidney perfusion

      ·5 A slower gastrointestinal transit time

      ·6 Atrophy of the gastric glands and decreased secretion of digestive enzymes

      ·7 A decrease in immune response

      ·8 A decrease in body mass and water volume that affects nutrition, metabolism, and the pharmacokinetic activity of drugs

      ·9 A decrease in the number of drug receptors and less affinity for drugs at the receptor sites

These changes may affect drug sensitivity and emphasize the need for health care professions to be aware of the effects of pain treatment on the aging adult.

The pain response is in part determined by a patient’s cultural background. Many older people do not complain of pain because they think that it is a sign of weakness or old age. There are exceptions, but in general people from Asia, Northern Europe, and American Indians tend to be more stoic in their expression of pain. Individuals from Latin American countries, the Middle East and Africa tend to be more expressive about their pain (Showalter, 2001). In assessing the expression of pain, the health care team must understand the myriad of beliefs and backgrounds that influence the patient.

As the aging population continues to grow and require pain management services, it is imperative that the specialist be aware of the many factors that influence pain perception and expression and use this knowledge to accurately assess, diagnose and treat this population.