Elderly Flashcards
Prevalence of chronic pain in elderly people, risk of under-treatment
20-30% of elderly people living in communities suffer from pain
45-80% of residents in nursing homes (USA) show substantial pain
pain is mild to moderate, often intermittent
Myth 1: pain is normal in old people
Myth 2: there is not much what can be done about pain in old people.
Methodological problems
Lack of longitudinal studies on evolution of pain sensitivity and pain states; only the cross-sectional studies are available allowing only statements about differences between young and old persons
The birth-cohort effect: people born at different times differ in their original psycho-social environments, and attribute different meanings to the pain
Lack of definition of an “old” person: 60, 70 or 90 years?
Harkins (2001, In: Bonica’s Management of Pain, Chapter 45) suggested the categories “young-old” (65-75 years) and old-old (76-90) but no consensus has been established.
Asessment of pain in old people with good mental capacities
The use of numerical or verbal scales in elderly is preferable.
The psychometric characteristics of the McGill Pain Questionnaire are equally good in old and young people (Gaghliese and Melzack, 2003; Gagliese and Katz, 2003).
Self-reports in old people, if possible to acquire, have the same reliability and validity as in young adults.
Elderly people may not use VAS appropriately to report their pain because of incomplete and unscorable responses (Chibnall and Tait, 2001).
Elderly people themselves do not like VAS because they find this instrument difficult for use (Gagliese and Melzack, 2006)
Caution is necessary when using visual analogue scales (VAS) with elderly patients. As many as 30% of cognitively intact elderly may be unable to complete this scale.
VAS has poor convergent validity, or lack of agreement with other measures, including the VDS
(Gagliese & Katz 2003)
Modified “Faces” pain scales, used in children, are also useful
Potential bias
Stoicism
Yong et al., 2001)
Developed the Pain Attitude Questionnaire that measured attitudes toward chronic pain. The PAQ was administered to 373 healthy persons who were subsequently divided into four age groups to test for differences in stoicism and cautiousness, two attitudes that have previously been claimed to influence pain perception and report among older adults.
Age-related increase in degrees of reticence to pain, self-doubt, and reluctance to label a sensation as
painful was found, emphasizing the need for careful consideration of pain attitudes in older patients who may underreport their pain symptoms.
Psychological recommendations for pain assessment in old people
Ferell, 2004
Frame questions in the here and now
• Most paitens with mild to moderate cognitive impairment can report pain reliably
• Use questions that are concrete and require only yes or no responses
• Use repetition
• Use validating questions
• Use communication aids (ie, glasses, hearing aids, lighting, positioning)
• Give adequate time for response
Experimental pain
Age does not affect the number of free nerve endings.
In contrast, numbers of tactile and pressure receptors (myelinated fibres) decrease with age.
Loss of dorsal horn neurons in older people contributes to decrease in endogenous inhibition and hyperalgesia:
Elderly people would show:
increased temporal summation of pain
decreased descending nociceptive control
reliance on C fibre mediated pain
Chakour et al. 1996
Analysed pain threshold and pain intensity during CO2 laser stimulation in 15 young and 15 old subjects
The stimuli were applied in the presence or in the absence of A-fiber blockade.
Pain threshold was greater in old compared to young subjects but only when A fibres were functioning. This implies that elderly rely on their pain reports more on the second pain, mediated by the C-fibres.
Harkins et al. 1996
Reaction times to first pain were significantly shorter in young compared to old subjects both for the leg and arm stimulation. However, old and young participants did not differ in the reaction time to second pain.
Edwards and Fillingim, 2001
Older subjects showed greater pain intensity and unpleasantness during the late pulses than young subjects
Lautenbacher (2012) conducted a meta-analysis of 52 studies analysing age effects on pain functions
Pain thresholds increase with age, especially for radiating heat and visceral distension.
Females show slightly stronger age-related increases in pain thresholds than males
Experimental pain: decreased DNIC
DNIC means inhibition of pain by other pain. DNIC is blocked by naloxone (LeBars et al., Pain, 48: 13-20, 1991) suggesting an effect of the endogenous opioid system
Edwards , 2003
Groups of young (mean 22 years) and old (mean 63 years). Thermal summation of heat stimuli applied to the left leg in the presence of cold pain in the right hand was smaller in young than in old subjects suggesting decreased DNIC (opioid-receptor mediated) in old people. Decreased functioning of the endogenous pain modulation in healthy elderly persons
In spite of large variability in the methodology, age groups, stimulations etc., there is a prevailing view that pain thresholds, especially for thermal and visceral pain, increase with age.
Pain tolerance threshold and the strength of descending nociceptive control decrease with age causes more pain for pains of high intensity and long duration, and greater pain in the presence of another pain.
Chronic pain: greater or smaller post-operative pain and chronic pain in old compared to young adult people? Quality of pain?
(Gagliese and Katz, 2003).
Post-operative pain was smaller in old (~66 years) than young (~56 years) patients
The difference only popped up in MPQ and PPI but not in VAS
Old people used less morphine than younger people, however, younger people dropped their morphine doses over successive days faster than old people.
Findings of the severity of acute pain in older and younger patients are variable (Gagliese and Melzack, 2006) but more studies report smaller MPQ values of acute post-operative pain in older than in younger patients (Gagliese et al., Pain, 2005). There are divergent results about the intensity of chronic pain in young and elderly patients, which may be related to the prevailing use of VAS instruments.
Gagliese and Melzack 2003
Assess age differences in pain intensity and quality
The elderly group had significantly lower MPQ total and sensory scores and chose fewer words than the young group (less pain).
Leong et al. 2007
Aging is associated with greater risk for many illnesses and the prospect of multiple, concurrent disease states
Over 50% of the sample had three or more comorbid problems.
Groups with greater levels of comorbidity scored higher on the Present Pain Intensity Index, the sensory and affective subscales of the McGill Pain Questionnaire
Greater levels of comorbidity are associated with reports of severe pain, depressive symptoms, reduced activity, and higher physical impact from pain
Problem of mental deterioration in relation to pain
brain regions and mental functions involved
Damage to different brain areas has been associated with both increases and decreases in pain intensity and affect (Melzack & Wall 1988).
Preliminary evidence that cognitive impairment is associated with changes in brain responses to noxious
stimulation is available (Benedetti et al 1999); however more research is needed to adequately address this issue
Pain assessment in people with dementia: which methods are available, and what do they tell us about pain in patients with dementia
Dementia shows 2-3% prevalence at 65 years, and 25-75% at/over 85 years, which means that significant part of chronic pain patients also suffers from Dementia.
Patients with dementia are at very high risk of untreated pain and suffering due to diminished interest to communicate their perceptions. Symptoms of dementia include withdrawal or agitation/aggression, which is a confounding factor in a behavioural assessment of pain.
Pain in dementia results from:
Dementia-associated musculoskeletal, cardiovascular, and gastrointestinal problems
Oral and dental problems
Ageing itself – postherpetic neuralgia. arthritis
(Husebo et al., 2014)
Administration of analgesics has been shown to decrease agitation in demented patients – a clear indication that patients experienced pain
Self-report not viable in about 50% of demented patients: the only solution is to employ observational methods (facial expressions, behaviour observation scales
Dalen-Kok et al., 2015
22 studies involving dementia patients showing clinical pain
5/8 studies focusing on agitation found positive associations between pain and agitation/aggression, 3 studies found negative associations
7/11 studies found positive associations between pain and depression, 4 no association
No associations with psychotic symptoms
Impairment of executive functions correlates with pain in dementia (Kunz et al. 2015) Executive functions (abstract thinking, judgments) correlated with the level of experimental pain Speculation: is this correlation due to functional losses in prefrontal cortex which is known to modulate the endogenous opioid system?
Kunz et al, 2009
46% of dementia patients were not able to give a report of pain
Incapacity to provide pain rating correlated with scores of mental impairment
Intensity of facial expressions of pain was increased in people with dementia
Dementia patients show stronger facial expressions of pain compared to age-matched healthy old people: Kuz et al, 2007)
Behaviour observational methods in dementia.
Reasons for their use.
Types of pain behaviour monitored.
Problems encountered.
The most important behavioural scales.
Rules to follow in behavioural observation in dementia patients.
Facial experssions (Grimacing, mouth opening, wincing) Vocalisations, Body movements, changes in interpersonal interactions, changes in activity patterns, mental status changes
Number of scales are available for assessment of pain in demented people; they include behavioural measures and measures of social interactions
DOLOPLUS2 (Behavioural pain assessment in the elderly, 10 items evaluating somatic; psychomotor; psycho-social dimentions) and PACSLAC (60 items evaluating facial expressions; activity/body movements; social and physioloical dimentions) have the best psychometric parameters and are used frequently (Zwaghalen et al., 2006)
Non-opioid (paracetamol, non-steroid anti-inflammatory durgs) and opioid drug treatment - number of side effects and dosage problems (decreased function of kidneys and liver cause slow metabolisation of drugs).
TENS, ointments, massage, mild physical therapy and exercise
Mindfulness meditation, guided motor imagery, biofeedback, cognitive behavioural therapy work often better than pharmacological treatment in elderly people
Recommendations
Always ask about pain
Reinforce that pain is not a normal part of ageing
Use validated pain assessment instruments, appropriate to patient’s cognitive level
Assess psychological distress, quality of life and functional impairment
Combine pharmacological and non-pharmacological interventions
Involve family caregivers
Repeat assessments regularly
Modify treatment plan to maximize function and pain relief
Summary
Old people feel clinical pain similarly to young people, although some of the pain manifestations and symptoms may appear atypical.
The method of pain measurement matters: visual analogue scales are less appropriate than verbal/numerical scales
Older people acquire a stoic attitude towards chronic pain, which may lead to under-treatment of their pain. However, older people shoud be explained that pain is not a normal part of aging, and that it can be controlled.
Age-related decreases in tolerance and DNIC appear to be the strongest contributors to clinical pain in the elderly.
An increased prevalence of dementia in the ederly may lead to withdrawal, and decreases communication of pain – risk of undertreatment of pain.
