Pain Control in the Elderly and Individuals with Dementia

Chronic Pain in the Elderly Population

• Persistent pain (three to six months) is present in 25–50% of older adults, and increases with age. Nursing home patients may have prevalence as high as 45–80%.33
• Chronologic markers for old age are arbitrary; however, various factors such as socioeconomic impacts, health-style choices and medical comorbidities may all factor into a patient’s physiologic age.

Evaluation of the Elderly Patient

• Identify the source of the pain and the impact that pain is having on the patient. Assess previous consultations, workups, and imaging studies. Be suspicious of increases in pain above baseline as pathologic pain promoters are much more likely with advanced age.
• Cognitive impairment resulting from delirium, dementia, or other mental health conditions may make both the assessment and management of symptoms more difficult.
• In a patient with complicated emotional issues, they may describe the pain in imprecise, inconsistent terms.
• Poly-pharmacy is common. Be aware of potential adverse effects from multiple medications.
• Imaging should be symptom and examination driven. Avoid duplication of previous testing.
• The management of symptoms in the older patient follows the same principles as that in younger persons. However, the elderly are more sensitive to medication side effects.34

Goals of Treatment

• The goals of treatment are modulated pain; ability to perform valued activities; improved function; to feel well enough to socialize; to have additional freedom from chronic, painful conditions; and enhanced quality of life.35
• Persistent pain is multifactorial. It is a treatable but not curable condition. Let the patient know that although pain may not be eliminated, substantial improvement in function is a realistic goal.

Non-Pharmaceutical Approach

• Often beneficial, with low cost and minimal side effects.
• Includes physical therapy, occupational therapy, acupuncture, chiropractic, and massage therapy. When ordering therapies, be sure to specify what conditions you want targeted and your goals of treatment. Monitor the modalities to ensure that they are being applied appropriately (positioning, hot/cold).
• Behavioral – Cognitive behavioral therapy and meditation along with patient education.
• Localized therapy – Joint injections and trigger-point injections.
• Continue these treatments when introducing medications to minimize medications and their side effects.

Pharmaceutical Approach

Non-opioids

Non-opioids are preferred over opioids. Used primarily for nociceptive pain (post-op pain, mechanical low back pain, injuries/trauma, arthritis). Involve a pharmacist for help in reviewing side effects and concomitant medications (including supplements) for drug-drug/supplement interactions.

• Acetaminophen is the first-line approach to mild, persistent pain:
  • Acetaminophen lacks inflammatory activity; therefore it’s effects may be limited in the long-term treatment of inflammatory conditions.
  • Beware of potential drug interactions and drug-dosing limits (determine the doses of all acetaminophen-containing products).
  • Reasonable prescribing: 3 grams/24 hours OR fewer than 2 grams in frail patients, those more than 80 years old or those who use alcohol on a regular basis.
• Non-steroidal, anti-inflammatory drugs (NSAIDs)
  • Start at low doses in the elderly.
  • Use briefly; no more than one to two weeks during periods of increased pain.
  • Tailor the medication to the patient’s cardiac and GI risk factors.
  • For those at risk for GI complications, add a gastro-protective agent.
  • There is a potentially lower GI risk with non-acetylate salicylate or COX-2 inhibitors.
• Antidepressants-for chronic neuropathic pain (postherpetic neuralgia, neuropathic back pain, polyneuropathy, trigeminal neuralgia). All have increased side effects in the elderly.36
  • TCAs – Tricyclic antidepressants have been shown to have effectiveness preventing migraine and tension headaches and in treating chronic pain. Common side effects are sedation, cognitive dysfunction, and orthostatic hypotension. Watch for drug interactions.
  • SNRIs – Selective noradrenalin reuptake inhibitors (e.g., duloxetine, venlafaxine) are frequently used in treating neuropathic pain.
  • SSRIs – Selective serotonin reuptake inhibitors (e.g., paroxetine, citalopram) have been used in the treatment of neuropathic pain. These agents may be particularly useful in elderly patients because of their favorable side-effect profiles.
• Anticonvulsants – gabapentin, pregabalin and carbamazepine may be effective for neuropathic pain. Use of these medications is frequently limited because of dizziness, somnolence, fatigue and weight gain. Tolerance improves over time. Side effects and potential for drug-drug interactions limit their utility in older adults.37
  • Start at low doses, titrate slowly upward, and taper off when stopping the medication.
• Transdermal lidocaine can be useful in the elderly to treat neuropathic and localized, nociceptive pain and has a low incidence of side effects.
• Muscle relaxants should be avoided in individuals older than 65 because of intolerance to side effects.

Opioids – General Considerations

• Opioid analgesics are the mainstay for the treatment of moderate to severe pain in patients with advanced illness. Long-acting or sustained-release analgesic preparations should be used for continuous pain. Breakthrough pain should be identified and treated by the use of fast-onset, short-acting preparations.
• Elderly are more sensitive to the effects of the opioids, due to age-related physiologic changes (e.g., decreased renal or hepatic function and altered body-fat distribution) as well as comorbid medical conditions.
• Always consider if there is an alternative therapy that is likely to have an equal or better therapeutic benefit for pain control, functional restoration, and improvement in the quality of life.
• Consider whether the patient (or caregiver) is likely to manage use of the opioid responsibly.
• Patients may require other forms of medication other than pills. These may be liquid, patch or injections. Try to stay with the least-complicated mode of treatment to help with compliance.
• Opioids can cause mental clouding, which may clear over time. However, there may be persistent sedation, cognitive and psychomotor impairment, hallucinations, dreams and nightmares while on the medication.
• Never initiate opioid therapy with patches or other long-acting opiates in opioid-naïve patients.
• Reasonable dosing recommendations should start at 30% to 50% of the recommended starting dose at the same dosing intervals, and then titrate doses upward in 25% increments for comfort and side-effect tolerance. There is substantial individual variation in the response to the different opioids, and the drug with the most favorable balance between analgesia and side effects cannot be predicted.
• Potential medication choices:
  • Morphine, oxycodone, hydrocodone +/- acetaminophen, hydromorphone, tramadol, fentanyl, buprenorphine. Avoid meperidine and methadone. When choosing a medication, identify the targeted goal of treatment, the preferred route of administration, the patient’s frailty and comorbid conditions along with your clinical experience.
  • Opioid side effects:
    • Constipation – There is little adjustment to this side effect over time. Constipation is predictable, so start prophylactic laxative therapy when initiating narcotics.
    • Balance/Falls
  • Particularly in patients taking poly-pharmacy, who are deconditioned, or who have vision difficulties.
  • If there is evidence of risk for falls, consider avoiding use of opioids.
  • Consider a possible referral for PT and mobility aids prior to initiating treatment.
  • Ensure a safe environment for the patient with impaired mobility. Consider a home safety evaluation through the appropriate agency.
  • Respiratory
  • Sleep apnea and sleep-disordered breathing are seen with narcotic use.
• The exaggerated respiratory depression seen with opioid use can be minimized by starting at low doses and with appropriate titration. Use significant caution when increasing doses, especially in elderly individuals with risk factors for sleep apnea.
  • Nausea is common. Nausea can be minimized with a slow titration upward in the opioid dosing.
  • Depression – Opioids may precipitate or worsen depression, which is a treatable condition that may respond to therapy.
  • Opioids affect the functioning of the hypothalamic-pituitary-adrenal axis, resulting in increased levels of prolactin, decreased levels of sex hormones and, rarely, secondary adrenal insufficiency.

Pain Treatment in Patients with Dementia

• Because chronic, non-cancer pain is more likely to be reduced than eliminated, ongoing pain reporting is common.
• In those with advanced dementia who may be unable to communicate verbally about their pain, you may need to evaluate their condition (and their response to treatment) by facial expressions, verbalizations, body movements, changes in interpersonal interactions, activity patterns and routines such as sleep disruption and appetite suppression. Multiple questionnaires have been developed with variable success rates in eliciting pain levels in persons with dementia, with no general consensus on which one is superior.38
• Patients may also exhibit striking out, refusing medications, agitation, delirium, increased restlessness, and social withdrawal. Rule out other potential infectious, metabolic, medication-related, and social-situation changes as possible causes for acute decline.
• Prescribe a trial of scheduled medications (be cautious with scheduled NSAIDs). Use a stepwise approach.
  • Start low, go slow, be aware of possible under treatment.
  • Monitor the patient carefully to balance the risks and benefits of the treatment.
• Be alert to herbal and dietary supplements taken by older patients who may not volunteer this information. They may be prone to drug-supplement interactions.
• Patients who don’t respond to one medication may respond to another.