sequences of undertreatment for pain

can have a negative impact on the health

and quality of life of the elderly, resulting
in depression, anxiety, social isolation,
cognitive impairment, immobility, and
Managing Pain sleep disturbances.4 Reasons that physi-
in Geriatric Patients cians often cite for inadequate pain con-
trol include lack of training, inappro-
Thomas A. Cavalieri, DO priate pain assessment, and reluctance
to prescribe opioids.2
As with other age groups, the
elderly have pain that can be classified
pathophysiologically as either nociceptive
or neuropathic in origin. Alternatively,
pain may be mixed, that is, having ori-
gins that are both nociceptive and neu-
ropathic. Nociceptive pain may be either
visceral or somatic and is due to stimu-
The elderly are often untreated or undertreated for pain. Barriers to effective lation of pain receptors. In the elderly,
management include challenges to proper assessment of pain; underreporting this stimulation may be the result of
by patients; atypical manifestations of pain in the elderly; a need for increased inflammation or musculoskeletal or
appreciation of the pharmacokinetic and pharmacodynamic changes of aging; ischemic disorders. Patients with noci-
and misconceptions about tolerance and addiction to opioids. Physicians can ceptive pain are treated pharmacologi-
provide appropriate analgesia in geriatric patients by understanding different cally with both opioid and nonopioid
types of pain (nociceptive and neuropathic), and correctly using nonopioid, agents as well as nonpharmacologic
opioid, and adjuvant medications. interventions.1,3 Neuropathic pain results
Opioids have become more widely accepted for treating older adults who from a pathophysiologic disturbance of
have persistent pain, but such use requires physicians have an understanding either the peripheral or the central ner-
of prevention and management of side effects, opioid titration and withdrawal, vous system. In the elderly, common
and careful monitoring. Placebo use is unwarranted and unethical. Nonphar- examples include postherpetic neuralgia
macologic approaches to pain management are essential and include osteo- and diabetic neuropathy. Patients with
pathic manipulative treatment, cognitive behavioral therapy, exercise, and spir- neuropathic pain are less likely to
itual interventions. The holistic and interdisciplinary approach of osteopathic respond to agents used to treat patients
medicine offers an approach that can optimize effective pain management in with nociceptive pain such as pain due to
older adults. bone metastasis, and more likely to
respond to adjuvant agents such as anti-
J Am Osteopath Assoc. 2007;107(suppl 4):ES10-ES16. convulsants and antidepressants. Pain
of mixed origins may respond to admin-
istration of agents that treat for both noci-
ceptive and neuropathic pain.1,4
Because diseases often have an atyp-
more likely to have arthritis, bone and ical presentation in the elderly, it has
P ain is a common complaint of the
elderly. As the number of individ-
uals older than 65 years continues to
joint disorders, cancer, and other chronic
disorders associated with pain.1 Between
been speculated that pain perception
may be different in older adults.
rise, frailty and chronic diseases associ- 25% and 50% of community-dwelling Although pain sensitivity and tolerance
ated with pain will likely increase. elderly have important pain problems.2 across all ages varies,5 it is generally
Therefore, primary care physicians will Geriatric nursing home residents have accepted that such differences probably
face a significant challenge in pain man- an even higher prevalence of pain, do not have a significant clinical impact.
agement in older adults. The elderly are which is estimated to be between 45% As is the case in the use of any med-
and 80%.3 ications in the elderly, older adults are
The elderly are often either likely to have an increased risk of adverse
Address correspondence to Thomas A. Cavalieri, untreated or undertreated for pain. Con- reactions from pharmacologic agents
DO, FACOI, Interim Dean, Professor and Director,
New Jersey Institute for Successful Aging, Univer-
sity of Medicine and Dentistry of New
Jersey–School of Osteopathic Medicine, One Med-
ical Center Dr, Stratford, NJ 08084-1354. This continuing medical education publication is supported by an educational grant
Dr Cavalieri has no conflicts of interest. from Purdue Pharma LP.
E-mail: cavalita@umdnj.edu

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administered for analgesia.This propen-
sity is likely due to pharmacokinetic
changes such as reduced renal excretion
and hepatic metabolism, as well as phar-
macodynamic changes that occur with
age, such as an increased sensitivity to
certain analgesics, particularly the opi-
oids.2,4 In addition, polypharmacy is a
contributing factor for the increased inci-
dence of adverse drug reactions.
For pain management to be effec-
tive in the elderly, physicians need to be
skillful in pain assessment; capable of
recognizing the importance of a holistic,
interdisciplinary team approach to care;
and knowledgeable of both pharmaco-
logic and nonpharmacologic approaches
to providing optimal analgesia.1,4
Assessment of Pain in the Elderly
Effective assessment of pain in the elderly
can be challenging. It requires an appre-
ciation that such discomfort may present
atypically, particularly in the cognitively
impaired. Because biologic markers are
not available, self-reporting is viewed as
the best evidence for the presence of pain
and the optimal way to assess pain inten-
sity.4 Pain has been described as the “fifth
Cavalieri • Managing Pain in Geriatric Patients
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vital sign,” and therefore, physicians
should regularly inquire about the pres-
ence of pain in their elderly patients. Pain
can be assessed, even in those with
dementia, using simple questions and
screening tools.6
Assessing pain in the elderly is often
associated with significant obstacles.
Older adults frequently fail to report pain
because they may view that it is an
expected part of old age or because they
are fearful that it may lead to more diag-
nostic testing or added medication.1
Some patients may accept pain as pun-
ishment for past actions.3 Rather than
admitting to the presence of pain, the
elderly may use terms such as “aching”
or “hurting.”7 Communication and cog-
nitive disturbances are additional bar-
riers to such assessment. Increased agi-
tation, changes in functional status,
altered gait, and social isolation may be
signs of pain in patients with dementia.6
A comprehensive assessment
should include a careful history and
physical examination and diagnostic
studies aimed at identifying the precise
etiology of pain. Characteristics such as
intensity, frequency, and location should
JAOA • Supplement 4 • Vol 107 • No 6 • June 2007 • ES11
Figure 1. Sample pain assessment scales for
use in the evaluation of pain in the care of the
elderly.
be described. Standardized geriatric
assessment tools to assess function, gait,
affect, and cognition should be used.8
Intensity should be assessed by using
one of several pain scales that have been
accepted for use in the elderly (Figure 1).
A verbally administered 0-through-
10 scale is an effective measurement of
pain intensity in most older adults. When
using this scale, physicians can ask
patients, “On a scale of zero to 10, with
zero meaning no pain and 10 meaning
the worst pain possible, how much pain
do you have now?” Some older adults,
particularly those with dementia, may
have difficulty using this scale. Other
tools such as a visual analog scale,
numerical scale, pain thermometer scale,
and pain faces scale can be helpful.1,4,9
Recently, evidence has established the
reliability and validity for the use of the
faces pain scale with older adults. 10
When possible, use of an interdisci-
plinary team approach to assessment and
management of pain in the elderly is
advantageous. These strategies need to be
sensitive to cultural and ethnic issues, as
well as to values and beliefs of patients
and their families. Once etiologic factors
are determined and therapy is initiated,
a pain log or diary is appropriate to
assess effectiveness of treatment. Physi-
cians should encourage patients to record
such documentation on a daily basis.
Regular reassessment by use of previ-
ously administered assessment scales is
important and serves to modify therapy
to assure an optimal response. Reassess-
ment should include an evaluation of
compliance and the presence of adverse
drug effects11 (Figure 2).
Pharmacologic Management
of Pain in the Elderly
Even though adverse drug reactions in
the elderly are a significant risk, phar-
macologic intervention for pain man-
agement is the principal treatment
modality for pain. Along with consid-
ering age-associated changes of phar-
macokinetics and pharmacodynamics,
 Figure 2. Suggestions for effective pain
assessment in the elderly.
physicians must consider the likelihood
of drug-drug and drug-disease interac-
tions. Despite these challenges, pain in
the elderly can be controlled but most
likely will require trials of various agents
and careful titration of dosages. Because
older patients may have increased sen-
sitivity to analgesic medications, lesser
dosages may be effective as compared
with effective dosages in younger
patients.12 This difference is especially
true when using opioid analgesics.
Inasmuch as there is still a paucity of
clinical trials that focus specifically on
geriatric patients, information regarding
initial and titrating medication dosages
may not be available. Therefore, initial
doses should be lower and titration
should be slower in the elderly. In addi-
tion, the general approach should be to
start with nonopioid medications for
treating patients with mild pain,
advancing to opioids for those with mod-
erate to severe pain. The selection of the
agent should be determined by targeting
the underlying pathophysiology if pos-
sible. For example, if pain is due pri-
marily to inflammation, an anti-inflam-
matory agent should be given. However,
if pain is predominantly neuropathic, an
anticonvulsant should be used. At times,
combinations of analgesics may be
required.
Selecting an agent likely to cause the
fewest side effects is paramount. Once
dosing is initiated, it is essential that pri-
mary care physicians regularly and care-
fully monitor for drug side effects and
adverse events.1,4 The use of placebos is
unethical, and placebos should not be
used in pain management,13 a position
that the American Osteopathic Associa-
tion (AOA) endorses in the statement
prepared by the AOA’s End-of-Life Care
Committee,14 now the Council on Pallia-
tive Care Issues. (See pages ES35-ES38.)
Nonopioid Analgesics
Most mild or moderate pain in the
elderly is of musculoskeletal origin and
responds well to acetaminophen given
around-the-clock. This agent is well tol-
ES12 • JAOA • Supplement 4 • Vol 107 • No 6 • June 2007
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Checklist
䡵 Consider pain as the first vital sign that is best measured by the
patient.
䡵 Ask about the presence of pain when examining an older person.
䡵 Console patient for atypical manifestations of pain in the elderly,
such as changes in function or gait, withdrawn or agitated
behavior, or increased confusion.
䡵 Use standard geriatric assessment tools to evaluate function,
affect, cognition, gait, and psychosocial issues.
䡵 Rely on the input of caregivers, particularly in elderly patients with
cognitive impairment and communication disorders.
䡵 Do a comprehensive pain assessment evaluating pain quality,
intensity, and factors that exacerbate or relieve the pain.
䡵 Use standard pain scales such as a numerical scale, a pain
thermometer scale, or a visual analog scale.
䡵 Identify the etiology of pain in the elderly (keeping in mind that it
may be multifactoral) by use of geriatric assessment tools, the
history and physical examination, and appropriate diagnostic tests.
䡵 Conduct a careful structural examination to identify regions of
somatic dysfunction.
䡵 Monitor and measure presence of pain regularly by use of a pain
log or diary and by readministering the pain scales to assess the
efficacy of the intervention.
erated in older patients provided that Opioid Analgesics
both renal and hepatic functions are Administration of opioid analgesics to
normal. 15 The daily dose of manage chronic noncancer pain in the
acetaminophen should not exceed 2 gm. elderly has become acceptable; these
Long-term use of nonsteroidal anti- agents are effective in treating patients
inflammatory drugs (NSAIDs), because with moderate to severe nociceptive pain.
of their association with gastrointestinal True addiction in the elderly is
bleeding and renal dysfunction, places uncommon, and the possibility of addic-
the elderly at significant clinical risk. tion should not be used as justification for
Although the likelihood of bleeding is undertreatment of the elderly for
lower with the concomitant use of miso- pain.1,18,19
prostol or a proton pump inhibitor, miso- Morphine sulfate and oxycodone
prostol is not well tolerated in the elderly. hydrochloride, now available in both
For this reason, a proton pump inhibitor short-acting and sustained-release prepa-
may be an optimal choice.16,17 rations, are commonly used. Short-acting
Because of their association with a opioids can be used in treatment of
lower incidence of gastrointestinal patients with intermittent pain, whereas
bleeding, selective cyclooxygenase-2 sustained-release opioids should be given
(COX-2) inhibitors (coxibs) have been for continuous pain (with short-acting
viewed as a safer alternative to the other preparations available for breakthrough
NSAIDs; however, concern about their pain). The dosage of sustained-release
association with heart disease and stroke opioids can be titrated based on the fre-
has dampened their acceptance and quency of use of the short-acting prepa-
resulted in the withdrawal of rofecoxib ration. For patients who may not be able
(Vioxx) from the market.17 Prolonged use to take oral preparations periodically,
of NSAIDs in the elderly should be opioids are available as parenteral, sub-
avoided whenever possible. lingual, suppository (oxymorphone
Cavalieri • Managing Pain in Geriatric Patients
 Figure 3. Suggestions for effective pharma-
cologic pain management in the elderly.
Checklist
䡵 Consider age-related alterations of drug metabolism resulting in to gastric hypomotility, patients need to
increased drug sensitivity and adverse reactions while using take stool softeners for as long as they
pharmacologic interventions for pain management in the are on opioid therapy. Chewing or
elderly.
crushing sustained-release opioids must
䡵 When considering pharmacologic interventions, keep in mind be avoided as doing so can cause rapid
that pain is often unrecognized in the elderly and the elderly are absorption of the entire dose resulting
often undertreated for pain.
in overdosing.1
䡵 Start with the lowest possible dose, and proceed slowly to Certain opioids should be avoided
increase dose.
in elderly patients when possible.
䡵 Consider acetaminophen as the drug of choice for mild to Propoxyphene is thought to be no more
moderate musculoskeletal pain. effective than aspirin or acetaminophen,
䡵 Nonsteroidal anti-inflammatory drug use should be avoided as but it is associated with ataxia, dizziness,
much as possible for the treatment of elderly patients who have and neuroexcitatory effects due to drug
persistent pain.
accumulation.22 Meperidine hydrochlo-
䡵 Consider opioid analgesics for moderate to severe nociceptive ride should not be used because of the
pain in the elderly. accumulation of a nephrotoxic metabo-
䡵 Use sustained-release opioids for continuous pain and short- lite. Methadone hydrochloride should
acting preparations for breakthrough or episodic pain. also be avoided in the elderly because it
䡵 Titrate opioid dose based on use of medications for has a long and variable half-life, which
breakthrough pain. makes titration difficult. In addition, the
䡵 Prevent constipation with opioid use by recommending a analgesic action is shorter than that of
prophylactic bowel regimen. respiratory depression1 so patients whose
䡵 Anticipate and manage opioid side effects such as sedation, methadone dosage is too low may
confusion, and nausea until tolerance develops. increase their daily amount, which
䡵 Avoid the use of opioids that have frequent adverse reactions in increases the risk of death from respira-
the elderly, such as propoxyphene, meperidine hydrochloride, tory depression.
and methadone hydrochloride. Transdermal fentanyl, contraindi-
䡵 Closely monitor patients on long-term analgesic therapy for side cated in opioid-naïve patients, should
effects and drug-drug and drug-disease interactions. also be used with extreme caution in the
䡵 Consider adjuvant analgesics such as the anticonvulsant elderly. It has a variable absorption rate
gabapentin for the management of neuropathic pain. in older adults and a long residual effect
even when the patch is removed.
Tramadol hydrochloride, an anal-
gesic that has some opioid properties
hydrochloride), and transdermal (eg, fen- could propel the patient on long-term and is used for mild to moderate pain,
tanyl patch) products.20 opioid therapy into withdrawal. It is should be used with caution in the
Physicians should anticipate, pre- advisable that patients take a mainte- elderly because it may cause dizziness
vent, and manage side effects. They nance dose for several days before they and reduce the seizure threshold.23
should initiate prevention of constipa- resume driving.
tion through the use of stool softeners Antiemetics such as prochlorper- Adjuvant Medications
and other prophylactic bowel regimens azine or metoclopramide may be needed Adjuvant medications are frequently
whenever opioid therapy is used in the early on with the initiation of opioid used to treat elderly patients with chronic
elderly. When opioid therapy is initiated, therapy. Falls, dizziness, and gait dis- pain disorders. Many were developed
sedation and delirium are commonplace turbances are not uncommon; therefore, for purposes other than analgesic use but
until tolerance develops. Although res- preventive precautions are often recom- have been shown to be effective in the
piratory depression occurs uncommonly, mended, such as the use of an assistive management of certain pain syn-
tolerance develops rapidly. If needed, device. Eventually, for most patients, the dromes.24 Anticonvulsants, steroids, top-
naloxone hydrochloride could be used analgesic effect of opioids is preserved ical local anesthetics, and antidepressants
for profound respiratory depression and while tolerance develops to most side are such agents that may be used alone
sedation; care must be taken when effects (eg, respiratory depression, seda- or in combination with nonopioid or
reversing this adverse effect since an tion, nausea, and vomiting).1,4,11,21 How- opioid analgesics.
antagonist action that is too powerful ever, because tolerance does not develop Adjuvant medications are particu-

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 Figure 4. Suggestions for effective non-
pharmacologic pain management in the
elderly.
larly useful in managing neuropathic
pain.4 Although tricyclic antidepressants
such as amitriptyline hydrochloride and
nortriptyline hydrochloride have been
used to treat patients with this disorder,
anticonvulsants such as gabapentin and
carbamazepine are thought to be more
effective.25 In addition, amitriptyline has
significant anticholinergic effects that can
be problematic for geriatric patients.
Gabapentin seems to be more effective
and better tolerated in older adults. How-
ever, the recently available anticonvul-
sant pregabalin is effective and easier to
tolerate than gabapentin.26
Selective serotonin-reuptake
inhibitor (SSRI) drugs are effective and
well tolerated when used for treating
patients with depression, but their effi-
cacy in pain management is not docu-
mented.1 More recently,however, sero-
tonin norepinephrine-reuptake inhibitor
(SNRI) in duloxetine, has been shown to
be effective for the treatment of patients
with neuropathic pain and seems to be
well tolerated in the elderly.27
When selecting an adjuvant agent
to treat the elderly for pain, physicians
should: (1) prescribe medications with
the lowest side effect profile for older
adults; (2) titrate the drug slowly; and
(3) assess patients carefully for both effec-
tiveness and the presence of adverse
effects1,2,4 (Figure 3).
Nonpharmacologic Pain
Management in the Elderly
Although most elderly patients require
pharmacologic intervention to manage
pain, nonpharmacologic approaches may
have an added benefit and should be
routinely considered. This aspect is par-
ticularly important in older adults
because procedures that avoid drugs
have a low frequency of adverse reac-
tions compared with pharmacologic
approaches.
Although many nonpharmacologic
methods lack rigorous, evidence-based
studies to document their efficacy, the
body of knowledge to substantiate their
ES14 • JAOA • Supplement 4 • Vol 107 • No 6 • June 2007
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Checklist
䡵 Realize the importance of nonpharmacologic approaches to pain
management, both alone or in combination with analgesics, as a
means of avoiding the high incidence of adverse drug reactions in
the elderly.
䡵 Recognize the importance and efficacy of patient and caregiver
education in the management of pain, enabling the patient and
caregiver to understand the goals of therapy, method of pain
assessment, appropriate use of analgesics, and self-help techniques.
䡵 Incorporate the appropriate use of osteopathic manipulative
treatment to reduce pain and enhance function.
䡵 Consider the role of cognitive-behavioral therapy as a means of
education and for enhancing coping skills and prevention of pain in
the elderly.
䡵 Recognize the role of exercise targeted to the individual as a means
of pain management to maintain and enhance functioning and
avoid deconditioning.
䡵 Consider the role of psychiatry or occupational therapy to avoid
dysfunction, improve muscle strength, and aid in identifying the
appropriate use of heat, cold, and massage therapy in the
management of pain.
䡵 Recognize that some older patients may be helped by other
nonpharmacologic therapy such as acupuncture and transcutaneous
electrical nerve stimulation.
䡵 Appreciate the spiritual aspects of pain in the elderly and provide
counseling or refer to a member of the clergy if appropriate.
use is increasing, particularly when such Osteopathic Manipulative
methods are used in conjunction with Treatment
drug therapy.15,28,29 Clearly, osteopathic manipulative treat-
ment is effective in the management of
Patient and Caregiver Education chronic pain.31,32 The type of techniques
Patient and caregiver education is essen- and the extent of intervention must be
tial as a mechanism to improve pain tailored to the individual.4 The holistic
management in the elderly. Patient edu- approach to care, central to the practice of
cation programs typically include infor- osteopathic medicine, supports the need
mation about the nature of pain, assess- for an interdisciplinary team approach
ment instruments, medication use, and to the care of elderly patients with chronic
nonpharmacologic treatment modalities, pain.31-33
as well as coping strategies. Both one-
on-one as well as group programs can Complementary and Alternative
be effective. Caregiver education is espe- Modes of Therapy
cially important in caring for the Evidence exists that participation in reg-
elderly.28,29 ular physical activity can reduce pain
and enhance functional capacity of older
Cognitive-Behavioral Therapy adults with persistent pain.34 Addition-
Cognitive-behavioral therapy using a ally, an assessment by a physiatrist, phys-
structured systemic approach to teaching ical therapist, or occupational therapist
coping skills has been shown to be effec- may be helpful for recommending ways
tive. It requires a trained therapist con- to improve muscle strength and avoid
ducting 6 to 10 sessions.1,30 dysfunction and also for identifying the
appropriate use of heat, cold, or massage
Cavalieri • Managing Pain in Geriatric Patients
 Figure 5. Ten principles for effective pain
management in the elderly.

䡵 The use of osteopathic manipulative treatment and the holistic

approach of osteopathic medicine in the management of pain in the The most useful approach in this patient
elderly optimizes care of older patients. would be the pain faces scale, which, as pre-
䡵 The use of placebos in the management of pain in the elderly is viously noted, has been found to be reliable
unacceptable, unethical, and unjustified. and valid for assessing pain in older adults.10
䡵 Regularly inquire about the presence of pain in the elderly and Given the patient’s mental status, her
consider pain as the “fifth vital sign.” responses to the other pain assessment
䡵 Keep in mind that pain is undertreated, underrecognized, and options—open-ended questions, numeric
frequently presents atypically in older adults. scale, pain thermometer scale, and use of a
䡵 An interdisciplinary, multidimensional approach to assessment, pain diary—would not provide an accurate
evaluating the physical, structural, functional, and psychosocial aspects indication of the severity of her pain, which is
of pain, using standard assessment tools is important to appropriate most likely of nociceptive and neuropathic
evaluation. origin.
䡵 When prescribing medications, be aware of altered drug metabolism An attempt to reintroduce long-acting
with aging and the presence of polypharmacy; when selecting opioids after careful titration resulted in only
pharmacologic interventions, be aware of the increased frequency of
minimal improvement in this patient’s pain.
adverse drug reactions in the elderly.
Therefore, pregabalin was added because of the
䡵 Acetaminophen is an effective analgesic for mild to moderate neuropathic origin of the pain. This addition
musculoskeletal pain in the geriatric population and should be
considered whenever possible in lieu of medications with higher side was supported by the nature of the pain and
effect profiles; long-term NSAID use should be avoided if possible. the lack of pain relief through the reintro-
duction of long-acting opioids.
䡵 Opioid analgesics are effective for chronic pain in the elderly; fear of
addiction is exaggerated; side effects must be anticipated and
prevented; and skill at dosage initiation, route of administration, and Comment
titration is important. The elderly are frequently untreated or
䡵 Adjuvant medications such as anticonvulsants and antidepressants are undertreated for pain because of barriers
effective in treating elderly patients for neuropathic pain. to recognition, assessment, and man-
䡵 Nonpharmacologic approaches such as patient education, cognitive- agement in such patients. A greater
behavioral therapy, physical therapy, and spiritual interventions understanding of clinical manifestations
should be included in pain management in older adults. of pain, improved methods of assess-
ment, and use of both pharmacologic
and nonpharmacologic interventions can
result in more favorable outcomes in the
therapy. Both acupuncture and transcu- which is representive of problems in pain treatment of older adults for pain. Osteo-
taneous electrical nerve stimulation have assessment and treatment decisions. pathic physicians are uniquely equipped
been used with modest success for man- for optimal care of elderly patients with
agement of persistent pain in older Case Presentation persistent pain by incorporating bene-
adults.4 Mrs Jones, an 80-year-old woman, has a his- fits of manipulative treatment and using
tory of Alzheimer disease in the middle stages holistic and team approaches of osteo-
Spirituality and metastatic breast carcinoma to bone. She pathic medicine (Figure 5).
Last, for many patients, there exists a has resided in a nursing home for the past
spiritual dimension to persistent pain; year. Lately, she has had increased agitation References
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2. Gloth FM III. Pain management in older adults:
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Cavalieri • Managing Pain in Geriatric Patients