The elderly populations are often undertreated or untreated for pain. Barriers to efficient management of pain include challenges to proper pain management assessments; atypical manifestations of pain for the elderly persons; and underreporting on the side of patients. Others barriers to effective pain management include misconceptions about tolerance; addiction to opioids and a need for increased appreciation pharmacodynamics and pharmacokinetic changes visible in the elderly. The clinicians and physicians can do an effective management of pain by gaining a proper understanding of the varied types of pain. The specialist should equally learn how to appropriately use opioid, nonopioid, and adjuvant medications. The interdisciplinary and holistic approach of osteopathic medicine gives an approach greatly optimizes management of pain in older adults.
Pain Management Issues
Pain remains a common source of complaint about the older adults. The population of the elderly continues to rise and so is the frailty and chronic diseases that are associated with pain are likely to continue rising. That, therefore, the primary care physicians will most likely face a significant challenge in dealing with pain management issues with the elderly persons. Malec and Shega (2015) mentioned that the older adults are more likely to have bone and joint disorders, cancer, arthritis, and other chronic ailments that are associated with pain. An average of between 25% and 50% of community-dwelling older adults has crucial problems of pain. The problem of pain rises for nursing home-dwelling elderly who are estimated to have a prevalence of between 45% and 80% (Mann & Carr, 2018).
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Some of the older adults are undertreated and that can have negative consequences on the health and quality of life resulting in depression, social isolation, anxiety, cognitive impairment, sleep disorders, and immobility among other issues. The physicians occasionally site for inadequate pain control can be accounted for by a lack of training, reluctance to prescribe opioids and inappropriate assessment of pain (Mann & Carr, 2018).
According to Malec and Shega (2015), the older adults have pain that can be categorized pathophysiologically in origin as either neuropathic or nociceptive. Alternatively, pain can occur in mixed forms. Nociceptive pain can be either somatic or visceral and is caused by the stimulation of the pain receptors. In the older adults, such stimulation can result in inflammation or ischemic disorders. The patients that have nociceptive pain receive their treatment pharmacologically using nonopioid and opioid, as well as non-pharmacologic interventions. On the other hand, neuropathic pain results from pathophysiologic disturbances from either the central or peripheral nervous system. Pains of mixed origins potentially respond to administering of agents that can treat both neuropathic pain and nociceptive pain (All, Fried & Wallace, 2017).
More often than not, (Mann & Carr, 2018) reiterated that diseases have an atypical presentation in the older adults and thus there are speculations that the perception of pain differs from one elderly individual to another. Pain tolerance and sensitivity varies across different age groups but that does not have a significant impact clinically.
Effective pain management in the elderly necessitates that the physicians gain a skillful pain assessment strategy. The specialist should be in a position of recognizing the significance of interdisciplinary and holistic approach to delivering care. In addition, they should be knowledgeable of non-pharmacologic and pharmacologic management approach (Mann & Carr, 2018).
Elderly Assessment of Pain
The process of efficient pain assessment in the older adults can prove to be so challenging. It necessitates an appreciation that pain potentially is present atypically, especially in the cognitively impaired. Since the biologic makes are not present, self-reporting is seen as the best evidence for the existence of pain and an optimal manner of assessing the intensity of pain. More often, pain is described as the fifth vital sign and as such, a majority of physicians regularly inquire of the presence of pain in the older patients (Horgas, 2017). It is possible to assess pain even in those with dementia by using basic queries and screening apparatus.
Malec and Shega (2015) alluded that the assessment of pain in the elderly is occasionally met with a number of obstacles. Most of the persons fail to include pain in their report since they predominantly view it as an expected part of old age. Some see as a factor that may factor that may lead to further diagnostic and additional medication. A section of the patients views pain as punishment for some of their previous actions in their productive ages. Instead of admitting the presence of pain, the older persons may use terms like hurting or aching. Cognitive and communication disturbances are added to this kind of assessment.
The usage of an interdisciplinary team approach to management and assessment of pain in the elderly is more advantageous. It is crucial to be sensitive to ethnic and cultural concerns, in addition to the beliefs and values of the patient. A pain log should be initiated to assist in the treatment effectiveness (Horgas, 2017). Regular documentation is resourceful in the modification of the therapy to ascertain optimal response.
Pharmacologic Management of Pain
Cao, Elvir-Lazo, White, Yumul and Tang (2016) confirmed that pharmacologic interventions for the management of pain are the principal modality of treatment for pain. Pain management in the elderly is controllable but needs trials of the varied agents and the careful administration of the medical dosages. Since the older adults potentially have increased sensitivity to analgesic reactions, lesser dosages are considered effective in comparison to efficient dosages in younger patients. Such a difference especially hold true for patients that use opioid analgesics.
Starting dosages need to be lower and titration should also be carried out in a slower rate. The general approach needs to start with nonopioid medications in the treatment of patients with mild pains, and later advance to opioids for the patients with moderate to severe pain (Horgas, 2017). The selection of that kind of agents needs to put into consideration the underlying pathophysiology.
Nonopioid Analgesics
A majority of mild to moderate pain in the older adults is of musculoskeletal origin and as such response efficiently to acetaminophen that is timely administered. The agent is greatly tolerated in elderly patients as long as those both hepatic and renal functions are normal (All, Fried & Wallace, 2017).
Opioid Analgesics
Of late, the administration of Opioid Analgesics for the management of chronic non-cancer pain in the older persons is acceptable. The agents are effective in the treatment of patients that have moderate to a severe state of pain. It is uncommon to spot true addiction in the elderly, and the potentiality of addiction need not be utilized as a justification for the under-treatment of pain in the older individuals (Cao, Elvir-Lazo, White, Yumul & Tang, 2016).
Particular opioids should face avoidance as much as possible. Propoxyphene is thought of as being more efficient as compared to acetaminophen or aspirin, but it is associated with dizziness, ataxia and neuro-excitatory effects due to drug accumulation (All, Fried & Wallace, 2017).
Adjuvant Medications
Adjuvant Medications are predominantly used for the treatment of elderly patients that have chronic pain disorders. A majority of these kinds of medications were developed for reasons other than analgesic usage but over time have proven to be effective in the relief and management of specific symptoms of pain. The medication is specifically resourceful in managing neuropathic pain. In older adults, gabapentin seems to be more efficient and more tolerated. Selective serotonin-reuptake inhibitor (SSRI) drugs are well tolerated and efficient when utilized for the treatment of patients that have depression, although their efficacy in the management of pain is not in documented materials. In the event of choosing an adjuvant agent to treat the elderly for pain, the physicians need to put into consideration the prescribed medications with the minimal side effects profile for the elderly individuals. It is important that they titrate the drug slowly and provide an assessment of patients carefully for both the presence of adverse effects and effectiveness (Malec & Shega, 2015).
Nonpharmacologic Pain Management in the Elderly
Despite the fact that older individuals require pharmacologic intervention for pain management, Nonpharmacologic strategies may contain added advantages and therefore, needs to be routinely considered. Such a consideration is specifically important in elderly persons since the procedures do not involve drugs and thus does not adverse reactions in comparison with pharmacologic approaches (All, Fried & Wallace, 2017). Several Nonpharmacologic strategies miss the rigorous, evidence-based research to document their efficacy. Despite this, the body of knowledge utilized to substantiate their usage is increasing, specifically in conjunction with drug therapy.
Patient and Caregiver Learning
Education of the patient and caregiver is instrumental as a mechanism to elevate management of pain in older adults (All, Fried & Wallace, 2017). Patient education programs essentially entail assessment apparatus, information on the nature of pain, medication usage, and nonpharmacologic modalities of treatment and coping strategies. Caregiver training is essential in caring for the elderly persons (All, Fried & Wallace, 2017).
Cognitive-Behavioral Therapy
This kind of therapy utilizes a structured systematic approach to training coping skills. The strategy has proven effective over time and requires a specialist therapist to carry out the training sessions (Tosounidis, Sheikh, Stone & Giannoudis, 2015).
Complementary Therapy Modes
It can censoriously be shown that regular physical exercise can potentially reduce pain and thus enhance the functional capacity of elderly persons that have consistent pain. Also, an assessment by a physical therapist, psychiatrist or occupational therapist may be resourceful. It is not only important for recommending ways of improving the strength of muscles and evading dysfunction, but also in the identification of the appropriate usage of cold, heat, or massage therapy (Malec & Shega, 2015). Transcutaneous and acupuncture electrical nerve stimulators have both been utilized with recommendable success for the management of consistent pain in elderly persons.
Spirituality
Horgas (2017) argued that there is a spiritual dimension of every person that is controlled by a supernatural being. A vast majority of patients take a spiritual route to cure the persistent pain. There is sufficient evidence that indicates high success rates and points out that spirituality is helpful to certain persons who are suffering from consistent pain. (Malec & Shega, 2015) emphasized that referral to an appropriate clergy and counseling may be instrumental in pain management.
Conclusion
The older adults are often undertreated or untreated for pain due to the barriers of assessment, recognition, and management of such kinds of patients. An in-depth understanding of clinical pain manifestations increased assessment methods, and the usage of pharmacologic and nonpharmacologic interventions can lead to suitable outcomes in pain treatment of elderly persons. Noteworthy is the Osteopathic physicians that are uniquely equipped for optimized elderly care of the elderly patients that have persistent pain by including manipulative benefits of treatment and team and holistic approaches to this line of medical administration. It is important to keep in mind that is under-recognized, undertreated and occasionally presents atypically in the elderly persons.
References
All, A. C., Fried, J. H., & Wallace, D. C. (2017). Quality of life, chronic pain, and issues for healthcare professionals in rural communities. Online Journal of Rural Nursing and Health Care , 1 (2), 29-57.
Cao, X., Elvir-Lazo, O. L., White, P. F., Yumul, R., & Tang, J. (2016). An update on pain management for elderly patients undergoing ambulatory surgery. Current Opinion in Anesthesiology , 29 (6), 674-682.
Horgas, A. L. (2017). Pain management in older adults. Nursing Clinics of North America .
Malec, M., & Shega, J. W. (2015). Pain management in the elderly. Medical Clinics , 99 (2), 337-350.
Mann, E., & Carr, E. (2018). Pain management. Foundation Studies for Caring: Using Student-Centred Learning , 259.
Tosounidis, T. H., Sheikh, H., Stone, M. H., & Giannoudis, P. V. (2015). Pain relief management following proximal femoral fractures: Options, issues and controversies. Injury , 46 , S52-S58.
