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APS Bulletin • Volume 17, Number 2, 2007
Special Interest Groups
David Williams, PhD, Department Editor
How Do We Best Treat Older Patients With Chronic Pain?
William Schwab, MD PhD AGSF
To address the problems of pain and its treatment in the elderly, APS recently formed a new Geriatric Pain Special Interest Group (SIG), chaired by William Schwab, MD PhD AGSF, program director of Geriatrics for the Ohio Permanente Medical Group. Geriatric Pain SIG members include researchers, clinicians, physicians, and nurses. APS Bulletin recently spoke with Dr. Schwab to discuss treating older patients with chronic pain.
Q: How can we best treat chronic pain in older patients?
A: The problem of pain in older patients is common, affecting up to 50% of the community-dwelling elderly and up to 80% of those who are institutionalized. Elderly patients oftentimes won’t complain of pain due to the perception that it is a normal part of aging. Many physicians will not treat it because of the same perceptions. When pain in the elderly is treated, it is often treated inappropriately. For example, NSAIDs are often prescribed with no stop date, despite significant risks to the kidney and stomach. Medications that are useful adjuvants in a younger population, such as amitriptyline, can have intolerable side effects in older individuals.
The catch phrase for geriatric prescribing is “start low, go slow.” Pain in the elderly is often chronic. I usually caution my patients that I am not going to try to immediately relieve all the pain, we will start with a little bit of relief and work our way up. The setting of expectations and goals of treatment is important in the elderly, as it is in all chronic pain patients. The goal should not be the complete relief of pain, rather the maximization of function.
Q: How can we combat the misperception that pain is a normal part of aging?
A: Information. The more a practitioner and a patient know, the better they do. The idea of pain as the “Fifth Vital Sign” is important (although I personally do not like the numeric scale in the elderly). By asking, the practitioner acknowledges that pain is an important part of the patient’s health and that it can be treated. The American Pain Society also has an important role in promoting excellence in both basic and clinical research and treatment of pain in the elderly.
Q: How does pain in the elderly differ from other populations?
A: The elderly represent a special population due to increased frequency of neuropsychiatric, neurocognitive, and neuropathic disorders such as dementia, depression, diabetes, and frailty. Pain treatment occurs in the context of social support systems that range from very poor to excellent. Patients may not be able to afford medications and may be ashamed to admit they need financial help. Responses to analgesics can differ from the young both in terms of initial and chronic response. For instance, there is evidence that there is less analgesia from the initial dose of an opiate although the dose necessary to maintain analgesia requires less medication. The elderly have well-described differences in the metabolism and elimination of medications and their metabolites. In addition, there may be differences in the mechanisms of the perception of pain with the increasing frequency of neurodegenerative disease in the elderly.
Q: What other issues should pain physicians be aware of when treating this age group?
A: When treating older patients, be aware of comorbidities, comorbidities, comorbidities—psychiatric, social, and medical. Pain is very rarely the single health issue for an 85-year-old. Other issues that are important for the successful treatment of pain in the elderly are cognitive status, social support and safety, depression, falls, and medication safety. Many elderly patients are on a plethora of medications with a significant possibility for adverse interactions. Common side effects such as constipation, mental status changes, and falls may not be volunteered by the patient and should be specifically questioned. Given the complicated social, psychiatric, and medical problems that are often present, a team approach is often needed.
Q: How do we improve treatment for the elderly?
A: Now, that is a broad question and it deserves a broad answer. There needs to be progress in both the basic and the clinical aspects of pain biology and medicine in the elderly. As stated before, both practitioners and patients need to increase their knowledge of pain in the elderly. Doctors need to ask if their patients are in pain, and the patients need to tell their doctors. We do have evidence that there are differential responses to painful stimuli and pain relieving medications in the elderly, but we know very little from a mechanistic point of view. We don’t even have good clinical data about the relative safety of NSAIDs, opioids, and adjuvants which constitute the mainstays of pain treatment in the elderly.
Q: What initiatives does the Geriatric Pain SIG have planned?
A: We are trying to organize a symposium on pain in the elderly for next year’s meetings. We hope to work with APS and the American Geriatrics Society to promote expert recommendations for pain treatment in the elderly. Most importantly, we are open to your suggestions. We encourage all interested members to join and participate in the special interest group.
The opinions and assertions contained herein are the private views of the interviewee and are not to be construed as reflecting the views of the Ohio Permanente Medical Group or the Kaiser Foundation Health Plan.
