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Pain in the Older Adult

Joy Linn and Mallory Miner

NURS 6644

Idaho State University

Pain in the Older Adult

Disease Process

Definition and Pathophysiology

One definition of pain is the broadly accepted definition from the International

Association for the Study of Pain (IASP). The IASP defines pain as “an unpleasant sensory and

emotional experience associated with actual or potential tissue damage, or described in terms of

such damage” (Rodriguez, 2015, p. 339). Another definition is the definition that most learned

during nursing school. This description is “whatever the experiencing person says it is, existing

whenever he says it does.” This definition places the patient at the center of the experience

(Rodriguez, 2015, p. 339).

Pain can be classified by duration, such as acute or chronic; type such as nociceptive,

neuropathic, or psychogenic; site such as muscle, joint, or visceral; or etiology such as trauma or

disease (Rodriguez, 2015, p. 339). Patients may also experience more than one type of pain at a

time. Acute pain is a time-limited, unpleasant sensation that serves to warn a patient to limit a

movement. Acute pain has an emotional, cognitive and sensory feature that occurs from tissue

trauma or damage. This pain usually resolves with healing. Acute pain also produces protective

reflexes, such as those that cause us to draw away from fire. Acute pain is usually categorized as

lasting up to six months (Rodriguez, 2015, p. 339).

There is no agreed on definition of chronic pain. It is commonly referred to as pain that

is without biological value, lasting longer than the typical healing time, not responsive to

treatments based on specific remedies, and of a duration great than 6 months (Katz, Rosenbloom,

& Fashler, 2015, p. 160). Chronic pain persists beyond the expected recovery period after the

trauma or injury, usually lasting longer than six months. Chronic pain can be disruptive to sleep

and activities of daily living. Chronic pain serves no protective or adaptive function (Rodriguez,

2015, p. 340). Chronic pain ranks among the most common, costly and incapacitating conditions

in later life. Painful conditions are one of the most common reasons that older people seek

health care in the ambulatory setting (Bicket & Mao, 2015, p. 577). Despite its high prevalence,

pain among older people is almost always the result of pathology, involving a physical or

psychological process. Combating this myth that “pain is inevitable with aging” represents one

of the educational challenges of being a healthcare provider (Bicket & Mao, 2015, p. 578).


Pain. The word conjures different emotions in each individual. None of the emotions are

positive ones. This experience is most prevalent among the elderly population. The elderly are

the fastest growing population of people in today’s society, and consequently, the pain that the

elderly commonly endure is become a more difficult and challenging problem for health care

providers to effectively manage. The U.S. Census Bureau in 2011 estimated that 20% of the

total population will be above the age of 65 in 2030. Approximately 66% of people over the age

of 65 report pain of some type, and the rate is higher for those individuals suffering from other

chronic illnesses and living in nursing homes (Jones et al., 2016, p. 1). Unfortunately, pain is

often underreported as some elderly patients, as well as healthcare providers, believe that pain is

a normal process of aging (Jones et al., 2016, p. 1).

Condition Specific Information


Chief Complaint. One of the types of pain is nociceptive. This pain occurs when

noxious stimuli active the afferent neurons. Some examples of nociceptive pain include a paper

cut on the skin, a femoral fracture, discomfort in the course of a cancerous tumor, or chest pain

during a myocardial infarction. This process occurs during four phases: transduction,

transmission, perception, and modulation (Rodriguez, 2015, p. 340).

Neuropathic pain consists of an injury to or alteration of the normal sensing and

modulating systems. There are many processes that are proficient at generating neural

modifications that produce neuropathic pain. One includes the reduced availability of m-opioid

peptide (MOP) receptors. The typical MOP agonist is morphine. The triggering of this receptor

by morphine causes analgesia, sedation and a minor drop in blood pressure, urticarial, euphoria,

decreased respirations, miosis, and reduced bowel motility (Rodriguez, 2015, p. 341).

Trauma may result in a “windup” phenomenon that concludes in a hypersensitivity

reaction. Inflammatory cells surround the areas of tissue injury and generate cytokines and

chemokines that typically regulate the progression of recuperation and tissue restoration. These

chemicals can also inflame and alter the properties of the sensory neurons surrounding the area

of injury, creating a sense of pain in areas neighboring those of real injury (Rodriguez, 2015, p.


History of Present Illness (HPI). Pain is the defining feature for many disease

diagnoses. It can serve as an index of the severity and activity of an underlying condition, a

prognostic indicator, and a determinant of health service use. Describing the epidemiology of

pain is challenging because of the subjective nature of the symptoms and a lack of consensus

regarding diagnoses and definitions. Identifying true first-ever episodes of pain, especially

musculoskeletal pain, is problematic because of recall over a lifetime. Many pain conditions are

episodic, with a large proportion of patients reporting symptoms that resolve and then recur with

varying time periods in between. The true incidence for most pain conditions may thus remain

unknown (Henschke, Kamper, & Maher, 2015, p. 140).

Pain has survival value. Pain serves as a warning that all is not well, frequently signaling

injury or disease. It encourages us to seek medical help, contributes to the healing process by

promoting rest and recovery, and let us know, by its absence, when to resume activities. Pain

reminds us of past harmful events and situations, it teaches us what to avoid in the future, and

motivates us to act to terminate it. People born without the capacity to feel pain often do not live

beyond childhood because they fail to appreciate the implications of injury and disease. Acute

pain serves this survival function. However, chronic pain has no adaptive purpose. When

chronic pain is severe and intractable, it lodges itself in the core of the person and causes distress

and suffering. Chronic pain can ruin marriages and families. It can lead to job loss and other

financial problems, social isolation, worry, anxiety, depression, and even at times, suicide (Katz

et al., 2015, p. 162).

Medication History- Non-steroidal anti-inflammatory drugs (NSAIDs) are among the

most frequently used drugs. They are used extensively in the management of chronic pain and

inflammatory conditions, such as rheumatoid arthritis (RA) and osteoarthritis (OA), as well as

acute pain due to trauma, surgery, headache, musculoskeletal injuries, and cancer (Wehling,

2014). Management of pain and inflammation must consider those risks and find alternative

drugs or approaches to limit the negative impact of NSAIDs on mortality and morbidity such as

alternative drugs, low-dose/short-term use, but especially non-pharmacologic approaches, such

as physiotherapy, exercise, neurophysiologic measures, and local therapies (Wehling, 2014).

Past Medical History- The history is important to characterize a patient’s pain in order

to provide timely relief and treatment. The elderly can experience multiple pain syndromes from

different areas of the body and this should be considered while contemplating a differential


Family History- Having a family history of substance abuse, family members who have

had problems with alcohol, drugs or prescription medication that caused health, relationship, job

or legal issues, are at an increased risk for substance use disorders based on diagnostic criteria in

the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Pestka, Nash, Evans,

Cronin, Bee, King, & ... Loukianova, 2015). Benefits of assessing family history include

heightened awareness of the genetic and environmental risks associated with a family history of

substance abuse, an opportunity to participate in motivational interventions to prevent or

minimize consequences of substance use disorders, and likely substantial overall health-care cost

savings (Pestka, Nash, Evans, Cronin, Bee, King, & ... Loukianova, 2015).

Social History- Patients with chronic pain and major depressive disorder (MDD) need to

be asked about suicidal ideation and/or hurting others as well as a through social history. Other

questions to ask about include unemployment or disability, poor sleep quality, and self-perceived

mental health status, feeling of belongingness and perceived burdensomeness (Cheatle, 2014). It

leads to job loss and other financial problems, social isolation, worry, anxiety, depression, and, at

times, suicide (Katz, Rosenbloom, & Fashler, 2015).

Constitutional- Patients with pain may feel at fault, disbelieved, and alone (Katz,

Rosenbloom, & Fashler, 2015). Untreated chronic pain in geriatric patients can result in

depression, poor quality of life, and loss of independence.

Pain- Geriatric pain assessment should be followed by a good history and physical exam.

It should be noted that meaningful pain scores can be more difficult to obtain in the elderly.

Assessment should also include the patient’s functional abilities.

Differential Diagnosis- An underlying medical illness or medication side effect has to be

ruled out before ever deciding that someone’s symptoms are caused by mental disorder (Katz,

Rosenbloom, & Fashler, 2015). Chronic pain may be localized (regional) or generalized and is

typically divided into five main possible categories, including myofascial, musculoskeletal

(mechanical), neuropathic pain, fibromyalgia and chronic headache (Pain Chronic Syndromes,


Current Standard of Care

Medical dosage adjustments are frequently needed in elderly patients, due to variances in

drug metabolism, drug interactions due to polytherapy, and increased sensitivity to side effects

(Pain Chronic Syndromes, 2016). Suggested starting doses for common pain medications have

been distributed by the American Geriatric Society (Pain Chronic Syndromes, 2016). The tactic

to treat chronic pain syndromes includes treatments that are designed to alleviate or minimize

long-term pain complaints, to prevent future occurrences/recurrences of pain, for severe

increases in the level of pain (Pain Chronic Syndromes, 2016). Most of these treatments will

require a multidisciplinary approach. The primary care physician should consider specialist


Diagnostic Tests

Plain x-rays of spine, bones and joints, identifies osteoporosis, fractures, osteoarthritis,

lytic bone lesions, arthritic changes. MRI of spine, identifies disc herniation with nerve root

impingement, lumbar stenosis and pathologic causes of pain. EMG and nerve conduction studies,

help identify and differentiate between peripheral causes of neuropathic pain, such as peripheral

neuropathy, and radiculopathy (Pain Chronic Syndromes, 2016).

Treatment, Complications and Monitoring. Treatment plans should focus on

minimizing patients’ functional limitations and relieving pain (Jones et al., 2016, p. 24). Opioids

can cause many of the elderly to fall and then further injure themselves. For this reason it is

important to consider all of the treatment options, for mild to moderate pain, (McCartney &

Nelligan, 2014) recommend to first exclude treatable causes such as infection, loosening of

components or mal alignment. For this the initial treatment could include acetaminophen 1 g

every 6 h prn or compound analgesic (acetaminophen/opioid combination). For moderate to

severe pain, they recommend adding oral opioids such as oxycodone or hydromorphone to

acetaminophen as required (e.g. hydromorphone 1–2 mg every 4–6 h prn). Furthermore, short,

carefully supervised courses of NSAIDS (especially COX-2 inhibitors) may be beneficial.

Finally, for moderate to severe pain (± neuropathic component) it is suggested that Gabapentin

100–300 mg every 8 hours titrated to effect up to 1,800 mg/day be used as well as Nortriptyline

25 mg at night. Also, topical capsaicin or lidocaine may be beneficial for selected patients. Non-

pharmacological and complementary treatments, we should first look at making sure their

depression is treated and then move on to cognitive behavioral therapy, acupuncture, TENS and

massage therapy (McCartney & Nelligan, 2014).

Health Care Costs

Chronic pain has not only an undeniable impact on a patient’s quality of life, but there are

also financial consequences. Caring for those with chronic pain can also lead to financial costs,

with the average costs being approximately $10,000 a year. Patients with pain also consume

close to twice as much health care resources as the general population. The total costs of the

cumulative burden of chronic pain, including the cost to patients, those who care for them, the

health care system, and the economy, is considerable. In the U.S., approximately 100 million

people were affected by chronic pain in 2010. The total costs ranged from $560-635 billion.

This annual cost is higher than for heart disease, cancer and diabetes (Henschke et al., 2015, p.



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