The Australian Institute of Health and Welfare (AIHW) has quoted the prevalence of chronic pain to be 20% between the ages of 65-74, increasing to 24% in those 85 and over. With an aging population, managing chronic pain in older adults has become an increasingly important area of healthcare, albeit with its challenges.
Assessing pain, a subjective experience, can be particularly challenging in older adult patients. They may struggle to describe the pain accurately or pinpoint its exact location, and often find it difficult to distinguish between different types of pain, such as musculoskeletal and neuropathic.
Some may underreport their discomfort, either because they believe pain is an inevitable part of ageing, don’t want to be seen as a burden, or worry it may signal a more serious condition.
Communication about their symptoms may be further complicated by cognitive impairments such as dementia or the side effects of medications. This makes it essential to use modified pain assessment tools such as PAINAD or PACSLAC, and to account for sensory impairments such as vision or hearing loss, which can also hinder effective communication.
It’s important to allocate additional time to gather collateral information from healthcare providers, family members or medical records. In many cases, functional assessments can provide valuable insights. Observing patients’ body language and movement while they perform activities that mimic their daily routine, combined with targeted physical examinations, can offer a more comprehensive understanding of their pain.
Comorbidities and polypharmacy
It is estimated that 28% of older adults have three or more chronic conditions, which complicates pain management in this population. Chronic conditions such as diabetes, osteoarthritis, osteoporosis, cancer, and the aftereffects of surgeries or injuries can each contribute to distinct types of pain.
For example, diabetes may lead to peripheral neuropathic pain, while an acute exacerbation of chronic obstructive pulmonary disease (COPD) with persistent coughing can cause rib cage pain. Similarly, vitamin D deficiency may result in widespread musculoskeletal discomfort.
The presence of multiple comorbidities often leads to an extensive list of medications, further complicating the choice of analgesics due to potential drug interactions and side effects. In some cases, the medications themselves can cause or exacerbate pain.
For instance, statins are known to cause myofascial pain, and certain osteoporosis treatments can result in long bone pain. These factors make it crucial to carefully consider both the patient’s overall medical condition and the potential effects of their medications when managing pain.
Distinguishing acute and chronic pain
Assessing, investigating and managing acute and chronic pain can be very different to each other. It is worth noting that the majority of acute exacerbations of chronic pain resolve without a major intervention. However, distinguishing between acute and chronic pain can be challenging in the older age group.
It is often the case that potential pain generators in this age group are multifactorial. For example, a mechanical fall causing muscular pain, leading to a period of reduced activity and rest which further complicating muscle deconditioning and musculoskeletal pain.
Inactivity worsens their underlying lumbar spine arthritis, and the presentation may become complex. Or in the case of a chronic lower back pain where potential pain generator can be from multiple sources, each necessitating a different approach and treatment.
In some cases, what appears to be an acute pain episode may actually be a manifestation of poorly managed chronic pain.
Psychological and social factors
It is crucial to recognise the influence of psychological and social factors on pain in older adults. Depression, anxiety, social isolation and the fear of becoming dependent can significantly affect how this population experience and report pain. Pain-related functional decline often leads to reduced social interactions, increasing the risk of depression, while untreated depression can, in turn, intensify the perception of pain.
Older patients may also be hesitant to seek help or medical care, often due to limited social support, a desire not to burden their families, or concerns about appearing dependent and potentially losing their independence. These dynamics highlight the need for a multidisciplinary approach to pain management.
Involving general practitioners, allied health professionals, and other specialists is essential to the provision of comprehensive care that addresses both the physical and psychosocial aspects of pain in this age group.
Key messages
- Pain assessment can be complex and challenging in older adults
- Effective pain management begins with a thorough assessment, aimed at identifying all potential biomedical sources of pain
- Consideration should be given to assess social and psychological factors that may influence pain perception and impact.
– References available on request
Author Competing interests – nil