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300 C. Roger GOUCKE
you any pain now?” “Have you had pain in the last
week or month or year?” “Have you had pain for
more than 3 months in the last year?”
With this background it can be seen that pain in
older persons, if not already, will become a significant
consideration for health care planning. As people age,
accommodation requirements and caring patterns
change. It is recognised that not all older patients
need the same level of care, some continue to live
independently into their 80s and 90s, while others
may need low-level hostel-type care. e more frail
and disabled older person may continue to be cared
for by families, while others will need high-level
care including nursing home placement. Educating
relatives, nursing home carers and nursing staff will
be an ongoing requirement [44].
Associated with increasing age is dementia. It has
been estimated that 28% of low-level residential
care residents and 60% of high-level residential care
residents have a diagnosis of dementia. Cognitive
impairment is even more prevalent with 54% of
hostel residents and 90% of nursing home residents
being cognitively impaired [53, 56, 65]. e
detection of pain is significantly reduced in those
with severe cognitive impairment [60]. Up to 40%
of Australian nursing home residents are totally
unable to report pain due to a major cognitive or
communicative disability[56].
As people age, they are more susceptible to age-
related degenerative conditions such as osteoarthritis
and painful peripheral neuropathy (Table 18.01).
However, it is important to remember that pain is
not a “normal” component of ageing, it will usually
be possible to find a cause whether it be from
physical pathology or psychopathology [36, 41].
ere are also notable differences in pain-related
clinical presentations in the older person. For
example, abdominal pain, non-cardiac chest pain,
migraine and facial pain are less common [38].
Physiological, psychological
and psychosocial
considerations
Threshold and tolerance
A recent meta-analysis of psychophysical measures
on pain threshold has clearly demonstrated an
increase in threshold with age [34] such that the
pain threshold of the average older adult appears
in the top 15% of values seen in younger adults. In
this paper, Gibson suggests that the decreased pain
sensitivity (increased threshold) might explain the
under-reporting of mild pain symptoms, which in
turn might increase the risk of undiagnosed disease
or injury — for example, “silent” myocardial
infarction or perforated bowel [38, 42]. ere is
also some evidence that the descending inhibitory
pain mechanisms are compromised by advancing
years [76]. Gibson’s meta-analysis also reviews
pain tolerance and shows an age-related decrease
in the ability to tolerate severe pain. In summary,
the increased threshold, but decreased tolerance
of severe pain, highlight the reduced plasticity of
the pain pathways in older persons, demonstrating
increased vulnerability [37].
Apart from the physiological changes that occur as
patients age, psychological and psychosocial effects
will also influence the way older persons present
with pain. e older person’s beliefs about pain and
its treatment may be different to those younger;
they and their families may also have different
expectations. We know that older persons appear
more stoic than other age groups, as do their coping
strategies (more praying and hoping) [35, 78].
e effect of retirement and social isolation as
their spouses and friends die, together with their
loss of independence and looming or actual
institutionalisation, will also impact variably on
older persons with pain [66].
Identication
Because pain is so common in older persons, it
may be dismissed as something to be expected and
therefore its importance underestimated. In those
older persons that can verbally report pain, their
report should be accepted and a proper assessment
then carried out. In those persons unable to report
pain because of cognitive or communicative
impairments, different strategies are required.
e language we use to ask older persons about
their pain may need modifying. It is recommended
that words such as “sore” or “hurt” are used rather
than the word “pain”. For example “Do you have
any ache, soreness or discomfort?” may be more
easily understood. e use of open-ended questions
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Pain in the Older Person 301
is also more likely to get a useful response. When
attempting to quantify the amount or degree
of pain, verbal quantifiers are preferable than
numerical scales. For example “Is your pain a big
problem, a medium problem or a small problem?”
Older persons often have attitudinal differences
to those of a younger age, often accepting that
pain is an expected part of ageing, that pain may
suggest worsening disease, that they may be seen
as complainers or as distracting physicians from
treating the underlying disease [68].
For those persons unable to answer simple questions,
usually due to increasing cognitive impairment and
dementia, observational charts are available [75].
It is important to identify if the pain behaviour
observed occurs at rest or only after a certain activity
such as dressing, walking or showering.
Assessment
Assessment must begin with a thorough history
and clinical examination of the patient (Table
18.02). is process in the elderly can be complex,
particularly if there are cognitive or communicative
impairments or dementia. It may be useful to
use a dementia assessment tool such as the Mini
Mental State Evaluation (MMSE) to aid evaluation
of mental function [28]. Even for older persons
with good cognition, impairments in hearing
or vision, or dysphasia and dysarthria following
cardiovascular accidents, can be troublesome
during the assessment process.
For cognitively intact older persons, whether living
independently in the community or in residential
aged care facilities, any of the self-report pain
assessment tools used in younger persons can
be used. ere is evidence that numerical rating
scales are less understood than verbal scales and in
some situations help from a health care provider
or significant other may be needed. With regard
to assessment tools for pain in older persons, they
should not be unnecessarily complex because this
age group can tire easily. Consideration of cultural
and linguistic diversity is also obviously important
in multicultural societies.
ere are a number of recent reviews covering the
range of assessment tools available for use in non-
verbal patients with dementia. However, none
of these tools is well validated or known to be
particularly reliable [43, 79]. e Australian Pain
Society in a guideline document for the management
of Pain in Residential Aged Care Facilities [39]
recommended the use of either the Painad or the
Abbey pain scale for patients with dementia who
are unable to communicate verbally [1, 75]. ese
scales use a template for recording behaviour that has
been associated with pain. For example: groaning or
crying, grimacing or frowning, rocking or guarding
a body part, confusion or refusing to eat and the ease
of consolability. For those patients with dementia
that still retain verbal skills, there is agreement that
their verbal pain descriptions should be accepted.
e Australian Pain Society has recommended that
for cognitively intact older persons that a modified
Brief Pain Inventory be used [18, 39].
ere is also agreement that multidimensional
tools are required to ensure that as many facets of
pain on the older person’s life can be assessed. A
good assessment tool should cover pain intensity,
quality, variability and course thoroughly. e
effect of pain on the individual’s life must also
be assessed; this should include its effect on
function and quality of life. Depression (including
Table 18.01 Factors and conditions associated with
persistent non-cancer pain in older persons
• Low back disorders (vertebral compression
fractures, facet arthropathies, spinal canal
stenosis)
• Degenerative joint disease (osteoarthritis)
• Rheumatoid and other inflammatory arthritides
• Crystal induced arthropathies (gout, calcium
pyrophosphate)
• Pressure and other skin ulcers
• Chronic leg cramps
• Peripheral vascular disease (rest pain,
claudication)
• Amputations (stump pain, phantom limb pain)
• Post-stroke pain syndromes
• Neuropathic pain (diabetes, postherpetic
neuralgia, carpal tunnel syndrome, trigeminal
and occipital neuralgia)
• Headache
• Oral and dental pathology
• Angina
• Constipation
• Immobility, contracture
• Mood disorders
Modified from Ferrell B, Pain evaluation and management
1995 and AMDA Clinical Practice Guideline 1999 [7, 25].
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302 C. Roger GOUCKE
the increased risk of suicide in depressed older
persons), anxiety, sleep disruption, appetite and
interruption or disruption of activities of daily
living, because of or as a direct effect of pain, need
to be recorded [5, 27].
As we age, increasing numbers of comorbid medical
conditions develop such as ischaemic heart disease
and degenerative joint disease. ese conditions may
or may not be painful. Assessing the contribution
of this incidental pathology may prove difficult, for
example, on radiological evidence of degenerative
change in lumbar vertebra.
Pain Management Options
Not all older persons living in the community
need help to manage their pain; indeed many cope
very well and even minimise their discomfort;
others manage with minimal help. However, when
pain becomes “bothersome”, a number of clinical
practice guidelines are now available [5, 7, 39]. It
must be noted that the evidence base on which
these recommendations are made is limited, mainly
because of the dearth of research on pain-related
topics that have actually included older persons.
While pharmacological management of pain in
older persons is often one of the first-line therapies
for persistent pain, efficacy is likely to be improved
when drug therapy is combined with non-
pharmacological treatments.
Physical therapies
Exercise within the physical capacity of the individual
should be the first choice of physical therapy. Isotonic
exercise involves resisted contractions of major
muscle groups through a prescribed joint range. It
has the advantage that it can be done lying, sitting
and standing; it is different to isometric exercise
and the traditional aerobic exercise recommended
for cardiovascular fitness. In isotonic exercise,
the resistance can be varied (for example: high-
or low-weight sandbags or differing strengths of
elastic ribbon) and the number of repetitions can
be monitored and, if necessary, supervised. ere
is most evidence supporting the value of isotonic
and aerobic exercises, which have been shown to
reduce pain in musculoskeletal disorders by around
30% [4, 14, 30, 31]. is type of exercise also has
a positive effect on depressed mood [69] and sleep
[70]. Aerobic exercise such as walking or cycling
involves sustained repetitive movements of large
muscle groups. However, it may be precluded in the
elderly because of frailty and comorbid conditions.
It has long been recognised that graduated exercise
can improve claudication distance in individuals
with peripheral vascular disease [50]. Stretching
Table 18.02 Factors relevant to a pain assessment
Pain history
• When pain began
• Severity
• Aggravating and relieving factors
• Site
• Quality
• Radiation
General medical history
• Relevant diseases (e.g. dementia, arthritis,
vascular, gastrointestinal, renal)
• Associated symptoms (e.g. nausea)
• Allergies
Physical examination
• Sites of reported pain and referred pain
• The musculoskeletal and neurological systems
• Signs of arthritis
• Sensory changes (including hyperalgesia and
allodynia)
Physical impact of pain
• Impact of pain on activities of daily living
• Spontaneous pain
• Evidence of activity
• Avoidance of activity
• Comfort on movement
• Functional assessment
Psychosocial situation
• Coping resources
• Beliefs about the cause(s) of the pain
• Cognitive state
• Family expectations and beliefs about pain
and stress
• Presence of anxiety and depression
• Effect on sleep
• Suicidal thoughts
Social impact of pain
• Relationships
• Activities
Review of medications and other treatments
• Treatments that have been tried
• Effectiveness of current therapies
Modified from the National Health and Medical Research
Council Acute Pain Scientific Evidence 2005 and the
American Geriatrics Society panel guidelines on Pain in
Older Persons 2002 [5, 9].
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Pain in the Older Person 303
exercises are often recommended for individuals,
whether old or young; however, there is a lack of
evidence in the literature to support this activity to
improve pain or mood.
Superficial heat in the form of hot packs or
blankets has been reported as a comfort measure
[64], but there is lack of evidence for pain relief.
ere are always concerns of damage to skin and
deeper tissues, especially in patients with decreased
cognitive function and dementia. Superficial cold
likewise cannot be recommended for pain relief in
the older person [15].
Transcutaneous electrical ner ve stimulation (TENS)
is widely used in the management of chronic pain
in adults. It has some evidence for analgesic activity
in degenerative joint disease. It is a cheap and
simple technique and could be used in those older
persons who are able to report the stimulation
sensation [16, 57, 62]. ere is evidence that if
used intermittently for at least 40 minutes at a time,
that up to 30 minutes analgesia can be achieved
[17]. TENS machines should produce a firm but
comfortable stimulation over the area of perceived
pain. e precise parameters need to be determined
by trial and error (so cognitive function needs to be
reasonable) both low frequency or “acupuncture-
like TENS” of 2 – 5 Hz or high frequency 80 – 100
Hz appear to be effective [16].
Acupuncture is widely used for the treatment of
chronic pain in both Western and Traditional
Chinese Medicine, there is current interest in
explaining its apparent efficacy and increasing trials
to demonstrate this. In general though, it is still
considered a complementary therapy by Western
practitioners, and its use for chronic pain problems
can make application time consuming. erefore, it
may not be cost-effective or practical [12, 67, 77].
Cognitive or psycho educational
therapies
Pain is a sensory and emotional experience,
consequently when a nociceptive or neuropathic
source either cannot be found or even if found
cannot be “cured”, it is current practice to address
these components of pain by using a psycho-
educational approach.
Cognitive (thought) behavioural (actions) therapy
(CBT) is the technique most often used to apply
psycho-educational therapies to patients (Table
18.03). ere is good evidence for using these
techniques in adults with persistent pain but also
specifically in older persons [5, 19, 24, 73]; as well
as reduced pain, increased coping skills, engagement
in social activity and overall quality of life have been
described. is type of therapy must be delivered by
trained therapists and will usually include a clinical
psychologist with support from other members of
the health care team, in particular nursing staff to
help reinforce the therapy.
e psychological components of persistent pain,
for example, anxiety and depression will also be
addressed as part of a CBT approach.
Typical CBT programmes run over a period of
weeks and can be full time or part time, residential
or with day attendance. ey consist of a structured
programme which, while often generic, can be
individualised depending on the precise issues
raised between the patient and therapist [24, 46,
74]. More detail about CBT can be found in
Chapter 38.
Pharmacological therapies
Paracetamol
Paracetamol is the most recommended medication
for first-line management of mild to moderate pain
in older persons, and can also be recommended for
additional use in severe pain when opioids are being
used [5, 39]. e maximum dose of 4 g per day
appears safe unless there is a history of high alcohol
intake, liver dysfunction, dehydration, prolonged
fasting or poor nutrition, when the dose should be
decreased. Paracetamol is available in combination
Table 18.03 Cognitive behavioural therapy
interventions
• Modification of beliefs and attitudes about
pain
• Teaching new coping methods
• Stress reduction techniques
• Goal setting
• Planned behavioural reactivation
• Pacing of physical activity
• Education about the nature of pain and its
consequences on mood, function and quality
of life
• Relaxation training
• Distraction and imagery techniques
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304 C. Roger GOUCKE
with many other compounds and available over
the counter, consequently a thorough medication
history may be necessary to identify non-prescribed
doses
Non-steroidal anti-inammatory drugs
(NSAIDs)
Cyclo-oxygenase (COX-1) and (COX-2) drugs are
also commonly prescribed for the elderly. While
they have both analgesic and anti-inflammatory
effects, they also have significant and serious side
effects.
Both these groups of drugs should be used with
caution in older persons. ey are associated
with an increased risk of upper gastrointestinal
(GI) haemorrhage, renal dysfunction with fluid
and sodium retention, increased blood pressure,
peripheral oedema and reduced glomerular
filtration. If used in combination with angiotensin
converting enzyme inhibitors and diuretics, the
so-called “triple whammy” effect can occur with
significant risk of drug induced renal failure [3]. As
with many drugs in the elderly, if selective COX-
2 inhibitors and traditional NSAIDs are indicated,
the lowest dose for the shortest duration should be
prescribed.
Some of the risk factors for GI bleeding include age
over 65 years, previous GI bleed and concomitant
use with medications such as warfarin, aspirin,
clopidogrel and corticosteroids. e GI side
effects of these drugs are becoming clearer; there
is evidence to suggest that COX-2 inhibitors are
less damaging than traditional NSAIDs (even with
a proton pump inhibitor or histamine-2 receptor
antagonist) to the gastric and lower bowel mucosa
[58].
Debate has arisen recently about their prothrombotic
effects. While rofecoxib has been withdrawn from
the market, attention has focused on this particular
side effect of all these drugs. Evidence is available
demonstrating as much risk of a myocardial
infarction for patients on diclofenac as there was
for rofecoxib [10]. ere is also a suggestion that
the risk of myocardial infarction is not necessarily
due to duration of the drug’s use, as appears to
be the case with the other NSAID-related side
effects. Levesque demonstrated a median time to
myocardial infarction with the use of rofecoxib of
9 days [51].
Opioids
ere have been a number of systematic reviews
and meta-analyses of randomised controlled trials
(RCTs) on the use of opioids in chronic non-cancer
pain published in the last few years [23, 32, 45].
While not specifically targeted at the older person,
the studies have included conditions such as
postherpetic neuralgia, painful peripheral diabetic
neuropathy and osteoarthritis, all of which are more
common in the older person. In these reviews, it
was difficult to determine the effects of opioids on
functional or quality of life outcomes.
ese meta-analyses have shown that there was
a significant placebo effect apparent during the
trials, with the mean decrease in pain intensity
being around 30% for the active arm and between
15–30% for the placebo arm. e mean decrease
in visual analogue scale pain score was 15/100.
Withdrawal rates in general were high with 5–10%
of patients leaving the study because of lack of
opioid efficacy (20% for placebo) and between 20%
and 30% withdrawing due to opioid related side
effects (5–15% for placebo). In general, side effects
were common with 50–80% of patients developing
at least one opioid-related side effect (30–60% for
placebo). Only 30% of the RCT patients remained
on “long-term” opioid therapy.
Older persons tend to be more sensitive to opioids
and appear to experience greater and more
prolonged pain relief [29]. ey are, however,
more prone to side effects. In a systematic review
of RCTs by Moore and McQuay (age groups not
specified), the most common opioid-related adverse
events were dry mouth (25%), nausea (21%)
and constipation (15%) [59]. Dizziness (14%),
drowsiness and somnolence (14%), pruritis (13%)
and vomiting (10%) were also common; however,
there was a high incidence of these symptoms in the
placebo groups as well [59]. In systematic reviews
by Kalso et al. [45] and Eisenberg et al. [23], the
number needed to harm (NNH) for opioids in the
treatment of chronic non-cancer pain were in the
following ranges: nausea 3.6–5.0, constipation 3.4–
4.6, drowsiness 5.3, vomiting 6.2–8.1, dizziness
6.7–8.2 and itchiness 13.
Tramadol
Tramadol is an atypical opioid analgesic
combining mu, noradrenergic and serotonergic
receptor agonist effects. Tramadol is effective in
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Pain in the Older Person 305
the treatment of moderately severe chronic pain,
particularly neuropathic pain such as postherpetic
neuralgia and painful diabetic neuropathy
[26]. Tramadol may produce less constipation,
respiratory depression, dependence, abuse and
diversion compared with standard opioids [2,
63]. Tramadol has a significant side-effect profile
in some people especially the elderly with nausea,
dizziness, delirium and hallucinations having been
reported. ere are some concerns particularly
when higher doses of tramadol are combined with
tricyclic antidepressants or selective serotonin
reuptake inhibitors with regard to provoking fits in
patients who have a reduced seizure threshold and
the possibility of the development of a serotonergic
syndrome [47, 48].
Buprenorphine
Although there is significant confusion in the
literature, buprenorphine is most commonly
classified as a (partial) mu agonist/kappa antagonist.
However, this is based largely on animal data and may
not necessarily apply in the clinical setting. ere is
some consensus that in lower doses commonly used
in clinical pain management, buprenorphine acts
more like a “full” mu agonist. e partial agonist
effect only occurs at very high doses as used in the
treatment of opioid addiction [20].
e use of buprenorphine in the treatment of pain
in older persons has increased significantly over
recent years, mainly as a transdermal system in
doses of 5–70 mcg/h. Transdermal buprenorphine
is effective in the treatment of non-cancer pain,
based largely on open-label surveillance data [52,
71], and a limited number of randomised placebo
controlled trials [72]. ere is limited evidence of
its efficacy in older persons
In summary then for the use of opioids in older
persons, the recommendations are to use low
doses for as short a period of time as is practical,
not to use opioids in isolation — always combine
with non-opioid analgesics and always implement
non-drug treatment strategies. Treat potential side
effects such as constipation and nausea proactively.
Adjuvant analgesics
Paracetamol should be considered the most widely
prescribed adjuvant drug, but usually this term
refers to the use of drugs not normally associated
with analgesia. ese drugs are usually prescribed
for neuropathic pain and include medications
such as antidepressants and antiepileptic agents.
ese drugs should be selected on their evidence
for efficacy for the underlying condition, their
side-effect profile, together with the cost and
availability.
e older tricyclic antidepressants have a long
record of use but have side effects especially in
the older person. Perhaps the best tolerated is
nortriptyline at a low dose of 5–10 mg at night.
Antiepileptic medications such as carbamazepine
have long been used to treat trigeminal neuralgia
and newer drugs such as gabapentin and pregabalin
have an increasing evidence base for efficacy in
neuropathic pain and are better tolerated in the
older person [61].
Interventional Techniques
ere are a range of interventional options that have
validity for persistent pain and may be considered
in the older person. Conditions likely to benefit
would include trigeminal neuralgia, peripheral
vascular disease, acute zoster and persistent spinal
pain.
Nerve blocks of the major divisions of the trigeminal
nerve using glycerol or balloon compression or
microvascular decompression via posterior fossa
craniectomy have a place if medical therapy fails
and have recently been reviewed [11]. A wide range
of spinal injections including facet rhizotomy for
back pain and epidural steroid injections for lumbar
radicular symptoms may also be of value [6, 49].
Postoperative Pain
Management
Advances in anaesthetic and surgical techniques
together with the changing demographics of the
population mean that more surgical procedures
are being offered to older persons. e presence
of coexistent diseases and multiple medications
make the management of postoperative pain more
challenging.
A recent review of the scientific evidence of the
management of acute pain identifies patient
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306 C. Roger GOUCKE
controlled and epidural analgesia as being more
effective in older persons than conventional opioid
regimens [9, 55]. e review also notes the age-
related decrease in opioid requirements allowing for
significant inter-individual differences. e verbal
descriptor scale in the acute pain setting may be
more reliable than other scales particularly in those
patients with cognitive impairment [33].
Summary
• Pain is common in older persons
• Assessment can be complex especially in those
with cognitive impairment and dementia
• Pain threshold is increased whilst tolerance
may be decreased
• e language of pain can be different; patients
use words such as sore, hurt, ache rather than
pain
• Assessment tools should be simple and
multidimensional
• A thorough history and examination will
usually find a cause for the pain; old age on its
own does not cause pain
• Targeted physical therapies along with
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