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Pain in older adults living in the community

Around the world, the population is ageing. Estimates predict that proportion of the world's population over 65 years old will rise from 7.4% to 16.4% by 2050, and the over-80 age group will more than triple in size.1 In the UK, 35% of babies born today will live to be 100 years old and there will be more adults over 50 years than under 50 years.2 

Pain problems seen in older adults include musculoskeletal syndromes such as osteoarthritis, spinal cord stenosis and fibromyalgia; but of course neuropathic pain syndromes can be seen as well. It is suggested that the most common sites of pain in the older population include back, hips, knees and other joints. Some studies show that 30% of men and 53% of women over the age of 55 experience peripheral joint pain.3 Furthermore, a range of potentially painful conditions including falls, leg ulcers, degenerative joints and cancer are seen within this group. Many of these conditions are well known and visible, yet it has been shown that the management of pain in this group is poor. There is a suggestion that this is related to the attitudes of healthcare professionals towards older adults experiencing pain, along with the fear of using many of the prescribed medications due to the increased potential for adverse effects.4 

Similarly, some of the research has demonstrated that these fears and anxieties regarding treatment exist within the older age group themselves, with suggestions of stoicism being rife as well as beliefs that pain should be a part of ageing that individuals should 'learn to live with'. Pain in older adults is more likely to continue for many years in this group and can impact dramatically upon ability to maintain independence and social interaction.

The multidimensional character of pain is emphasised by the National Guidelines in Assessment of Pain for Older People5 which describe pain at several levels:

 - Sensory dimension: the intensity, location and character of the pain sensation.

 - Affective dimension: the emotional component of pain and how pain is perceived.

 - Impact: the disabling effects of pain on the person's ability to function and participate in society. 

These guidelines recognise the need for a holistic, person-centred assessment and also that treatment may benefit from pharmacological and non-pharmacological methods of pain control.

A previous systematic literature review of pain assessment and pain management in older adults, funded by The Burdett Trust for Nursing, was completed in 2006 and again in 2007. This work informed guidelines or an 'algorithm' for pain assessment and management within the nursing home setting. Failure to empower staff to engage with the guidelines has resulted in the development of an iPhone application (see Resources). This tool is designed to provide and interactive pain assessment guide for staff working with people who are unable to communicate their pain. It has been evaluated recently by the South East Coast Ambulance service and the East of England Ambulance service and is gaining positive feedback. However, there is a considerable range of options to relieve pain that could be initiated and increasing evidence does exist to support their use.

Mild to moderate pain in the older adult tends to be ignored by the healthcare professional who is often content to do nothing. The alternatives - pharmacological strategies - are not without risks of unpleasant side effects, which may be unacceptable to the older adults themselves. A recent systematic review of the literature has been carried out and does demonstrate that most pharmacological approaches have been tested with younger adults and simply translated across to the older population.7 Nevertheless, paracetamol is viewed as a safe and effective option for pain management and should be taken regularly. Non-steroidal anti-inflammatory drugs (NSAIDs) have significant risks and patients should be monitored quite closely. Opioids can be prescribed and of course all side effects that are well known to occur with opioid drugs should be treated before they occur.

Other approaches that have recently been reviewed include some injection therapies, cognitive behavioural approaches, movement and exercise to improve function and some complementary therapies including transcutaneous electrical nerve stimulation and acupuncture. Injection therapies can be used to treat specific problems, for example intra-articular (IA) corticosteroid injections in osteoarthritis of the knee, local anaesthetic and corticosteroid nerve blocks for post-herpetic neuralgia and acute herpes zoster, and there is some evidence for the use of botulinum toxin in these patients. But all other invasive techniques have either weak evidence or no evidence supporting their use at all.7

Some complementary therapies such as transcutaneous electrical nerve stimulation (TENS) and acupuncture have some evidence supporting their use and there have been a few small-scale studies which have looked at the use of cognitive behavioural therapies in adults with dementia, living in care homes, which show promising results for the future.7

Self-management

There is no accepted definition of self-management8 and use of the term varies (lay-led or profession guided; disease-specific or generic). Self-management is commonly associated with the approach to chronic illness represented by arthritis care programmes such as those developed by Kate Lorig for people with arthritis. Typically they involve a focus on building patients self-efficacy for disease management through education.9 Self-management is also used synonymously with 'self-care', which has been defined as activities undertaken by the individual with a view to relieving symptoms, maintaining health, or preventing ill health.10 An alternative approach emphasises the use of the term in relation to the ways in which people 'self-manage' their own body, experiences and make health choices.11 In each case the emphasis is on the active involvement of the person with the disease. 

Conclusion and recommendations

There is no doubt that we are facing an ageing time bomb, with a dramatic increase in older adults, and more seriously, a dramatic increase in the 'oldest old' who may be more frail and likely to have more debilitating pain problems. In contrast we are facing a decrease in the younger population who are able to care for this ageing group, so the future face of healthcare will need to change. Acute services are hugely stretched even now and are likely to become more so in the future. The majority of care will be delivered in the community. So community staff have a wonderful opportunity to make a difference in the management of pain for the older population. 

We have seen strong guidelines in recent years which enable us to both assess and manage pain in the older population. Nurses working in the community should promote best practice by applying these guidelines. Having said all of that, there is a real need for research into all aspects of pain management and assessment. There is an opportunity for collaboration between clinicians and researchers to lead the research agenda in the future. The following are areas for future research:

More prevalence studies with different age cohorts defining chronic pain and specific forms of chronic pain, along with qualitative work that helps to understand the difference in pain experience between younger and older adults and the impact upon quality of life and independence.

More research into the use of pain assessment and implementation of a national pain assessment protocol.

Rationale prescribing and consistent monitoring of drug use and prevention of sides effects.

More research with older adults to explore preferred self-management approaches, complementary therapies and adjuvant techniques.

 

Resources

iPhone application demonstration

 

References

1. US Census Bureau. International Programs Center, International Database

2. Office of National Statistics. 2012.

3. Elliott A. Prevalence of pain in older adults. In Schofield P et al (ed) Pain Guidelines for Older Adults. Age & Ageing. March 2013.

4. Schofield P. Pain Management in Older Adults. Medicine 2013;41(1).

5. Schofield PA. 'It's your age': the assessment and management of pain in older adults. BJA - Continuing Education in Anaesthesia, Critical Care and Pain. 2010;10(3):93-5.

6. Collett B, et al. Assessment of Pain - National Guidelines. British Pain Society & British Geriatric Society. 2007.

7. Schofield P, et al. Guidelines for the management of pain in older adults. Age & Ageing. March 2013.

8. Boyers D, McNamee P, Clarke A, Jones D, Martin D, Schofield P, Smith B. Cost-effectiveness of self-management methods for the treatment of chronic pain in an aging adult population. Clinical Journal of Pain 2012.

9. Newbould J, Taylor D, Bury M. Lay-led self-management in chronic illness: a review of the evidence. Chronic Illness 2006;2(4):249-61.

10. MacKichan F, Paterson C, Henley WE, Britten N. Self-care in people with long term health problems: a community based survey. BMC family practice 2011;12(1):53. 

11. Kendall E, Ehrlich C, Sunderland N, Muenchberger H, Rushton C. Self-managing versus self-management: reinvigorating the socio-political dimensions of self-management. Chronic Illness 2011;7(1):87-98.