Managing pain in the older person

Abstract

Our population is ageing. In 1961 592 people celebrated their 100th birthdays. In 2012 14,500 celebrated and in 2035 an estimated 110,000 will be a hundred years old (ONS, 2012). There are now over 428,000 people aged 90-99. This presentation will examine the prevalence of pain, types of pain, how ageing and long term conditions impact on pain and treatment considerations and how to work with the older person to improve pain control, minimise side effects and maximise concordance.

Key words: Ageing: Pain: prevalence: Types, Management

Pain is defined as

“unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage”(IASP, 1994)

Research indicates that around 53 percent of older adults (those aged 65 and over) have experienced bothersome pain every month. Most (around 75 percent) had pain in multiple sites. Women, people who were obese, had musculoskeletal conditions or symptoms of depression reported a higher prevalence of pain. People with pain were less able than those without pain (Patel et al, 2013). People with dementia are more likely to experience pain than those who do not have dementia (Hunt et al, 2015). Pain is associated with impaired mobility and balance and increases risk of falls (Patel et al, 2014). Chronic pain is common in older people and affects the ability to move around freely, to sleep well and live a full life (Reid et al, 2015).

What types of pain does the older person experience

The older person may experience chronic pain due to osteoarthritis or muscular skeletal conditions and pain secondary to cardiac and respiratory conditions and pain secondary to long term complications of conditions such as diabetes such as peripheral neuropathy (Reid et al, 2015: Hunt et al, 2015: Patel et al, 2014). The older person may experience acute pain such as post herpetic neuralgia following an acute infection or pain following a fall and fracture or pain secondary to a collapse of osteoporotic vertebrae (Nazarko, 2014). Its important to differentiate between types of pain as this will guide treatment choices.

How to determine treatment options

It’s vitally important that we put the patient and his or her needs and wishes at the heart of all treatment decisions. In order to discuss treatment options the clinician needs to determine the cause of pain, whether the cause can be treated and whether treatment aims to support the patient whilst the cause if treated or if the pain must be managed long-term.

National guidelines on the assessment of pain in older people are currently being reviewed. The principles outlined are taken from current guidance (RCP, 2007).The clinician also needs to be aware of the person’s medical and drug history, comorbidities, allergies and intolerances.

How ageing affects treatment considerations

Age related changes cause reduced ability to absorb and excrete drugs (Wooten, 2012: Miller, 2007: Miller, 2000: Nguyen & Goldfarb, 2012: Esposito et al, 2007: Mühlberg & Platt, 1999). Key changes are:

• Reduced gastrointestinal motility and reduced gastro-intestinal blood flow• Changes in distribution of drugs due to decline in muscle mass and increase in fat

1

Managing pain in the older person

• Reduced ability to metabolise drugs due to decreases in hepatic blood flow and liver mass

• Reduced ability to excrete drugs due to decline in renal function• Changes at molecular level that alter receptor binding and may increase or decrease

sensitivity to particular classes of drugs.

How comorbidities affect treatment options

The older person may have cardiac, renal, gastro-intestinal, respiratory or cognitive comorbidities.

Almost 200,000 people in the UK have heart failurei. The incidence of heart failure rises dramatically with age; around 13 percent of men and 12 percent of women aged 75 and over have heart failure (Townsend et al, 2012). Chronic kidney disease (CKD) increases with age 1.9% of people under 64 have CKD stage 3-5, 13.5% of people aged 65-74 and 32.7% of people aged 75 and over (Public Health England, 2014, P 4).The older person is at increased risk of gastro-intestinal (GI) disease and each year 1% of people aged 80 and over are hospitalised as a result of GI bleeding. The commonest causes is peptic ulceration other causes include oesophageal varices and diverticular disease (Yachimski & Friedman, 2008).Around 10 percent of people aged 65 and over have asthma, this may be confused with chronic obstructive airways disease, underdiagnosed and treated (Gillman& Douglas: 2012). Non steroidal anti-inflammatory drugs (NSAIDs) contraindicated in cardiac failure as they can increase oedema and worsen cardiac failure. They can lead to exacerbation of asthma and can be nephrotoxic. Opiates and codeine based drugs should be used with caution in older people especially those with renal impairment. Cognitive impairment can make it difficult for the older person to manage medication.

Dysphagia affects around 11 percent of adults living in the community (Holland et al, 2011).It Swallowing difficulties can lead to the person being unable to take medication. In the past soluble medications have been used however there are now concerns that these contain high levels of sodium and increase blood pressure and non fatal strokes (George et al, 2013). Liquid medicines can often be suitable if a person has swallowing difficulties.

Considering drug interactions

The older person’s comorbidities and general frailty may place the person at risk of falls. These comorbidities and age related changes make the older person vulnerable to the effects of medication that can be given relatively safely in younger people. Medication can destabilise existing conditions or increase the risk of adverse effects such as falls) Basger et al, 2012, Barber et al, 2009; Laaksonen et al, 2010).

Recent research shows that around half of the 20 medicines most commonly prescribed for older people can increase the risk of falls. Medications that affect the central nervous system; hypnotics, sedatives, analgesics and antidepressants," were of particular concern”. They found that opioids doubled the risk of injurious fall in men and women and some non-opioid painkillers were also linked to a 15% to 75% greater risk of fall injuries (Kuschel et al, 2014) Medication review has been shown to significantly reduce the number of falls in people living in care homes (Zermansky et al, 2006).The American Geriatrics Society (2012) produce the Beers Criteria of potentially inappropriate medications for older people and this can be useful in alerting clinicians to potential side effects and interactions.

Enabling and facilitating concordance

Adults often don’t take prescribed medication (van Dulment et al, 2007) only about 60% of adults with long term conditions take medicines regularly enough to obtain any benefit

2

Managing pain in the older person

(McGavock, 1997) A number of sources can alert the clinician to medication non compliance. These include a history of not collecting repeat medicines, history from family and carer givers, the discovery of large amounts of unused medicine in the person’s home and the person’s own account. When a person is not taking prescribed medication it’s important to ask why (Wright, 1993). Medication review and minimising medication can increase the chances of the person taking prescribed medication and minimise risk of side effects.

Working with the older person and caregivers to identify and manage side effects

Despite the cant about consumerism healthcare is at the end of the day about relationships. It’s important to develop an open and honest relationship with the older person and his or her caregivers so that they are aware of possible side effects. Sometimes side effects can be managed with other drugs and at other times its best to switch drugs. If the older person and his or her caregivers feel that they can establish a dialogue with the clinician any side effects can be addressed.

Treating pain

Be guided by the World Health Organisation (WHO, 1998) analgesic ladder. If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids e.g paracetamol; then, if necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. T

The WHO ladder is part of an overall pain treatment method that centres on five key principles:

1. "By Mouth": use the oral route whenever possible, even for opioids2. “By the Clock”: For persistent pain, provide medication at regular intervals3. “Around the clock rather than prn4. "By the Ladder": 5. For the individual

ConclusionIt’s important to be aware that managing pain often requires a team approach and that all interventions do not require a prescription. The older person may benefit from walking aids, therapy, acupuncture or other non drug treatments (Abdulla et al, 2013).

3

Step one

Paracetamol one gram QDS - people weighing 45kg or less may require reduced dosesNSAIDS - beware of cardiovascular risks- Naproxen safest. Beware of renal, cardiac, asthma and other contraindications

Step two

Codeine - beware of renal impairement, be alert to side effects, constipation, nausea and those unable to metaboliseNeurophatic pain options gabapentin and pregabalinTramadol - be aware of multiple contraindications in older people

Step threeOpiates- be aware of side effects and falls risk

Managing pain in the older person

Recommended reading

Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P; (2013). Guidance on the management of pain in older people Age Ageing 42 (suppl 1): i1-i57 http://ageing.oxfordjournals.org/content/42/suppl_1/i1.full?sid=0ff4d625-b94f-4869-9eb8-faeec198136dAccessed 31st December 2015

American Geriatrics Society (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society. New Yorkhttp://www.guideline.gov/content.aspx?id=37706

http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdfAccessed 31st December 2015

References

Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P; (2013). Guidance on the management of pain in older people Age Ageing 42 (suppl 1): i1-i57 http://ageing.oxfordjournals.org/content/42/suppl_1/i1.full?sid=0ff4d625-b94f-4869-9eb8-faeec198136dAccessed 31st December 2015

Access Economics (2009) Future Sight Loss UK 1: The economic impact of partial sight and blindness in the UK adult population. RNIB. Full report available at: www.rnib.org.uk/researchAccessed 31st December 2015

Action on Hearing Loss (2011). Statistics. Action on Hearing Loss, Londonhttp://www.actiononhearingloss.org.uk/your-hearing/about-deafness-and-hearing-loss/statistics.aspxAccessed 31st December 2015

American Geriatrics Society (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society. New Yorkhttp://www.guideline.gov/content.aspx?id=37706http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdfAccessed 31st December 2015

Barber ND, Alldred DP, Raynor DK, et al (2009). Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. Qual Saf Health Care: 18:5: 341–3466

Basger, B. J., Chen, T. F. and Moles, R. J. (2012). Application of a prescribing indicators tool to assist in identifying drug-related problems in a cohort of older Australians. International Journal of Pharmacy Practice, 20: 172–182.

Esposito C, Plati A, Mazzullo T, Fasoli G, De Mauri A, Grosjean F, Mangione F, Castoldi F, Serpieri N, Cornacchia F, Dal Canton A. (2007). Renal function and functional reserve in healthy elderly individuals. J Nephrology.; 20:5:617-625.

George J, Majeed W, Mackenzie IS et al (2013) Association between cardiovascular events and sodium-containing effervescent, dispersible, and soluble drugs: nested case-control study. BMJ 347:f6954http://www.bmj.com/content/347/bmj.f6954Accessed 31st December 2015

4

Managing pain in the older person

Gillman A, Douglass JA (2012). Asthma in the elderly.Asia Pac Allergy. 2012 April; 2(2): 101–108http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3345322/Accessed 31st December 2015

Haanpää M Attal N, Backonja M, Baron R, Bennett M, Bouhassira D, Cruccu G, Hansson P, Haythornthwaite JA, Iannetti GD, Jensen TS, Kauppila T, Nurmikko TJ, Rice AS, Rowbotham M, Serra J, Sommer C, Smith BH, Treede RD (2011). NeuPSIG guidelines on neuropathic pain assessment. Pain. 152:1:14-27

Holland G, Jayasekeran V, Pendleton N, Horan M, Jones M, Hamdy S (2011). Prevalence and symptom profiling of oropharyngeal dysphagia in a community dwelling of an elderly population: a self-reporting questionnaire survey. Dis Esophagus 24:476-480

Hunt LJ, Covinsky KE, Yaffe K Stephens CE Miao Y, Boscardin WJ, Smith AK (2015). Pain in Community-Dwelling Older Adults with Dementia: Results from the National Health and Aging Trends Study. J Am Geriatr Soc. 63:8:1503-1511. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3843850/Accessed 31st December 2015

IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk (1994). Part III: Pain Terms, A Current List with Definitions and Notes on Usage" (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Press, Seattle. http://www.iasp-pain.org/TaxonomyAccessed 31st December 2015

International Association for the Study of Pain (IASP)(2009). Acute Musculoskeletal Pain. IASP. http://www.iasp-pain.org/files/Content/ContentFolders/GlobalYearAgainstPain2/MusculoskeletalPainFactSheets/AcutePain_Final.pdfAccessed 31st December 2015

Knapp M, Prince M (2007) Dementia UK. The Full Report. A report into the prevalence and cost of dementia prepared by the Personal Social Services Research Unit (PSSRU) at the London School of Economics and the Institute of Psychiatry at King’s College London, for the Alzheimer’s Society. Alzheimer’s Society, Londonhttp://www.alzheimers.org.uk/downloads/Dementia_UK_Full_Report.pdfAccessed 31st December 2015

Kuschel BM, Laflamme L, Möller J (2014). The risk of fall injury in relation to commonly prescribed medications among older people—a Swedish case-control study. Eur J Public Health http://eurpub.oxfordjournals.org/content/early/2014/07/31/eurpub.cku120.abstract?sid=163fdf54-747d-4707-8077-89bf6f964777Accessed 31st December 2015

Laaksonen R, Duggan C, Bates I (2010) Performance of community pharmacists in providing clinical medication reviews. Ann Pharmacother 44(7–8): 1181–1190

Lin LC, Wu SC, Chen HS, Wang TG (2002), Chen MY. Prevalence of impaired swallowing in institutionalized older people in Taiwan. J Am Geriatr Soc.50:1118–1123

McGavock H (1997). A review of the literature on drug adherence. Royal Pharmaceutical Society of Great Britain. London.

Miller M (2000). Nocturnal polyuria in older people: pathophysiology and clinical implications. J Am Geriatric Society;48:10:1321-1329

5

Managing pain in the older person

Miller, S. W. (2007). Therapeutic drug monitoring in the geriatric patient in: J. E. Murphy (Ed.), Clinical pharmacokinectics (4th ed., pp. 45–71) Bethesda, MD: American Society of Health-System Pharmacists

Mühlberg W, Platt D (1999). Age-dependent changes of the kidneys: pharmacological implications. Gerontology.;45:5:243-253

Nazarko L (2014). Falls secondary to post herpetic neuralgia. Nurse Prescribing: 13: 1: 44-48http://www.magonlinelibrary.com/doi/abs/10.12968/npre.2015.13.1.44Accessed 31st December 2015

Nguyen TV, Goldfarb DS (2012). The older adult patient and kidney function. Consult Pharm. 27:6:431-44.

Office National Statistics (2012). What are the Chances of Surviving to Age 100? ONS, Waleshttp://www.ons.gov.uk/ons/rel/lifetables/historic-and-projected-mortality-data-from-the-uk-life-tables/2010-based/rpt-surviving-to-100.htmlAccessed 31st December 2015

Office National Statistics (2013). Estimates of the Very Old (including Centenarians), 2002 – 2011. ONS, Waleshttp://www.ons.gov.uk/ons/rel/mortality-ageing/estimates-of-the-very-old--including-centenarians-/2002---2011/index.htmlAccessed 31st December 2015

Patel KV, Guralnik JM, Dansie EJ, Turk DC (2013). Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study. Pain. 154:12:2649-2657.

Patel KV, Phelan EA, Leveille SG, Lamb SE, Missikpode C, Wallace RB, Guralnik JM, Turk DC (2014). . High prevalence of falls, fear of falling, and impaired balance in older adults with pain in the United States: findings from the 2011 National Health and Aging Trends Study. J Am Geriatr Soc. 62:10:1844-1852.

Procacci P, Zoppi M, Maresca M. Visceral Sensation. In: Cervero F, Morrison JFB, editors. Progress in Pain Research. Elsevier; Amsterdam: 1986. pp. 21–8.pp. 39

Public Health England (2014). Chronic kidney disease prevalence model. Public Health, England.www.yhpho.org.uk/resource/view.aspx?RID=204692Accessed 31st December 2015

Reid M Carrington, Eccleston Christopher, Pillemer Karl (2015). Management of chronic pain in older adults . BMJ, 350 :h532. Londonhttp://www.bmj.com/content/350/bmj.h532Accessed 31st December 2015

Royal College of Physicians (RCP) (2007). National Clinical guideline number 8: The assessment of pain in older people. Principles of pain assessment. : Royal College of Physicians, British Geriatrics Society, The British Pain Society, London. https://www.britishpainsociety.org/static/uploads/resources/files/book_pain_older_people.pdfAccessed 31st December 2015

Scholes S, Faudling S, Mindell J (2014) Chapter five: Use of Prescribed medicines. Health & Social Care Information Centre. http://www.hscic.gov.uk/catalogue/PUB16076/HSE2013-Ch5-pres-meds.pdf

Sikandar S, Dickenson AH (2012). Visceral Pain – the Ins and Outs, the Ups and Downs. Current opinion in supportive and palliative care. 6:1:17-26. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3272481/Accessed 31st December 2015

6

Managing pain in the older person

Townsend N , Wickramasinghe K Bhatnagar P, Smolina K, Nichols M, Leal J, Luengo-Fernandez R and Rayner M British Heart Foundation Health Promotion Research Group (2012). Coronary Heart Disease Statistics 2012. British Heart Foundation. Londonhttp://www.bhf.org.uk/plugins/PublicationsSearchResults/DownloadFile.aspx?docid=508b8b91-1301-4ad7-bc7e-7f413877548b&version=-1&title=Coronary+Heart+Disease+Statistics+2012+&resource=G608Accessed 31st December 2015

Turley R, Cohen S (2009). Impact of voice and swallowing problems in the elderly. Otolaryngol Head Neck Surg. 140:33-36

van Dulmen S , Sluijs E, van Dijk L , de Ridder D , Heerdink R ,Bensin J (2007) Patient adherence to medical treatment: a review of reviews. BMC Health Services Research 7:55doi:10.1186/1472-6963-7-55http://www.biomedcentral.com/1472-6963/7/55/Accessed 31st December 2015

Wooten, J. M. (2012). Pharmacotherapy considerations in elderly adults. Southern Medical Journal, 105, 437– 445http://sma.org/southern-medical-journal/article/pharmacotherapy-considerations-in-elderly-adults/Accessed 31st December 2015

World Health Organisation (WHO) (1998). WHO's cancer pain ladder for adults, WHO, Genevahttp://www.who.int/cancer/palliative/painladder/en/Accessed 31st December, 2015

Wright EC (1993). Non-compliance—or how many aunts has Matilda? Lancet: 342, I8876:909-913

Yachimski PS & Friedman LS (2008). Gastrointestinal bleeding in the elderly. Nature Clinical Practice Gastroenterology & Hepatology 5, 80-9http://www.nature.com/nrgastro/journal/v5/n2/full/ncpgasthep1034.htmlAccessed 31st December 2015

Zermansky AG, Alldred DP, Petty DR, Raynor DK, Freemantle N, Eastaugh J, et al (2006) Clinical medication review by a pharmacist of elderly people living in care homes--randomised controlled trial. Age and Ageing 35:586-591.

7

i The figure is 119,314