Dr Martin Johnson and Professor Pat Schofield (left) explore the prevalence of pain in older people and summarise the best evidence for a variety of approaches
  • Older people living in residential care homes experience more pain compared with older people living in the community
  • An older person’s level of cognitive impairment should be taken into account when assessing pain and the style of communication should be adjusted accordingly
  • Timing of medication should be adjusted according to the type of pain:
  • severe, episodic pain requires treatment with medicines with a rapid onset of action and short duration
    • continuous pain requires regular analgesia, possibly using modified release formulations
    • combination therapy may provide greater pain relief, with fewer
    • side-effects, than higher doses of a single medicine
  • Treatment should be monitored regularly and adjusted as needed to improve efficacy and limit adverse events
  • Non-pharmacological strategies, in combination with medication, should be considered
  • Pain is known to be a risk factor for falls in older people:
    • exercise is beneficial and should be tailored to the individual.

The population of the UK is ageing: by 2050, we are likely to see significant numbers of adults aged over 65, and the number of people aged over 80 years will have tripled by then. We also know that 50% of older adults living in the community have moderate to severe poorly-controlled chronic pain. This number increases to 80% in the care home population. It should, however, be borne in mind that there are vast differences in the definition of chronic pain used in the prevalence studies.

The first guidance of its kind in the UK, Evidence-based clinical practice guidelines on management of pain in older people1 was published in January 2013 and was a collaborative project between the British Pain Society (BPS)2 and British Geriatrics Society (BGS)3. It is, in the authors’ opinion, the most comprehensive and up-to-date guidance on pain management in older people currently available in the world. The guideline1 can be accessed freely at: ageing.oxfordjournals.org/content/42/suppl_1/i1.full

Scope and methodology of the guidance

The guidance was based on an extensive systematic review of the available literature carried out by a professional, multidisciplinary group. The guideline authors searched PubMed and CINAHL for relevant publications between 1997 and 2010 (a detailed summary of the search criteria is provided in the full guidance1). The literature reviewed was international and only English language studies were included. The authors reviewed approximately 5000 records covering the epidemiology and management of pain in older people living in the community, with the aim of providing best practice guidance for the management of pain to all health professionals working with older adults in any care setting. Older adults were defined as being over 65 years of age. The authors chose not to address guidance on the assessment of pain (published in 2007;4 an update is due to be published in April 2014). They also decided to focus specifically on the management of chronic pain, defined as ‘… that which persists beyond the expected healing time’.5 This is a more pragmatic definition than the often-quoted definition, ‘pain that persists more than three months’.

As well as therapies and interventions, the guideline discusses the impact that attitudes and beliefs (of the older person and their spouse/carer, and professionals) may have on older people’s experience of pain. It also explores the difficulties of assessing pain where there are problems of communication and cognitive impairment in older people. The updated national 2007 guidelines4 on the assessment of pain in older people will be recommending that behavioural pain assessment scales such as Abbey6 or Pain Assessment in Advanced Dementia (PAINAD)7 are used, along with words like ‘soreness’ or ‘hurting’, which may be easier for the person to understand.

Prevalence of pain in older people

The authors agree with previous studies, which suggest a 50% occurrence of chronic pain among older adults living in the community, rising to 80% of older people living in care homes.8 It is impossible, however, to determine a definitive prevalence of pain in older people because of variations in the definitions of pain, populations, and methods used in different studies.

The data nevertheless suggest that the most vulnerable, frail members of our society appear to have more pain.1

As regards gender, pain is more prevalent in older women than older men. The effect of age is inconsistent, with some studies reporting an increase in prevalence with age and others a decrease. Prevalence also varies by gender with regard to the site of pain. The three most common sites of pain in older people are:1

  • back
  • leg/knee or hip
  • other joints.

Specific epidemiological data on neuropathic pain in older people is limited, but it is estimated at 1.6%.9

Pharmacological approaches

There are very few studies that look at the effects of pharmacological interventions in older people. Generally, outcomes of studies conducted among younger counterparts are simply translated across and applied to older people. Nevertheless, there are some key messages in the guidance regarding pharmacological strategies for older people, as discussed below; see also Box 1 (below).2

Paracetamol

Paracetamol is an effective analgesic, particularly for musculoskeletal pain, and is well tolerated, but the recommended daily dosage (4 g/24 h) should not be exceeded.2 (The authors are aware of the recent controversy regarding paracetamol use during the drafting of NICE Clinical Guideline 177 on osteoarthritis10 and await further developments.)

Non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective analgesics but great caution is needed when they are used with older people because of their side-effect profile. Regular, proactive monitoring is required for gastrointestinal, renal, and cardiovascular side-effects, and drug-to-drug and drug- to-disease interactions.

If other safer treatments (e.g. paracetamol) have not provided sufficient pain relief, and prescribing an NSAID is considered essential, the lowest dose of the drug should be used for the shortest period of time and reviewed regularly. A proton pump inhibitor (with the lowest acquisition cost) should be co-prescribed with an NSAID or selective cyclo-oxygenase-2 (COX-2) inhibitor.1

Opioids

Specific opioids discussed in the guideline include:1

  • weak opioids
    • codeine
    • dihydrocodeine
    • tramadol
  • strong opioids
    • morphine
    • oxycodone
    • fentanyl
    • buprenorphine
    • hydromorphone
    • methadone.

In the short term, opioids may be effective for both cancer and non-cancer pains, but long-term data are lacking. Opioids may be appropriate for patients with moderate or severe pain, particularly if their pain is causing functional impairment or reducing their quality of life. For patients with continuous pain, the guideline suggests the use of modified-release oral or transdermal opioid formulations to provide relatively constant plasma concentrations.1

Treatment must be individualised and carefully monitored for efficacy and tolerability as there is marked variability in individual patient response to opioids. An initial ‘trial of response’ may be considered, where the patient is closely monitored when first given the drug. It is important that common side-effects of opioid therapy (including nausea and vomiting) are anticipated and suitable prophylaxis is considered. Appropriate laxative therapy (e.g. the combination of a stool-softener and a stimulant laxative) should be prescribed throughout treatment for all older people receiving opioid therapy.1

Pruritus is also of particular concern in this age group; opioids are a common cause of this distressing symptom. Treatment of opioid induced pruritis can include opioid rotation, dose reduction, or non-drug treatments such as cool compresses or moisturisers.11 Gender and age can increase the possibility of side-effects with opioid use.12

Box 1: Summary of pharmacological recommendations1

Paracetamol

  • use for musculoskeletal pain—do not exceed recommended daily dose.

NSAIDs

  • use with caution—the lowest dose should be used for the shortest period and be reviewed regularly
  • a proton pump inhibitor should be co-prescribed with an NSAID or selective COX-2 inhibitor, choosing the one with the lowest acquisition cost.

Opioids

  • use for moderate to severe pain
  • treatment must be individualised and carefully monitored for efficacy and tolerability
  • side-effects are common and should be anticipated.

Tricyclic antidepressants or anti-epileptics

  • anti-cholinergic side-effects may be problematic:
    • start with the lowest possible dose and increase very slowly, based on response and side-effects.

Topical lidocaine and capsaicin

  • limited efficacy in neuropathic pain—topical NSAIDs can be used for neuropathic pain, if the pain is localised.
  • NSAID=Non-steroidal anti-inflammatory drug; COX-2=cyclo-oxygenase-2

Adjuvant drugs—trycyclic antidepressants and anti-epileptics

Tricyclic antidepressants or anti-epileptics (alone, not in combination) may be considered for neuropathic pain. The patient should be started on the lowest possible dose, which should be increased very slowly, based on response and side-effects.1

Antidepressants

Although tricyclic antidepressants are effective, anti-cholinergic side-effects (e.g. dry mouth, constipation, ocular side-effects and urinary hesitancy) may be a problem, and these drugs should be used with caution. Indeed, tricyclic antidepressants are best avoided in patients with known heart problems.13

Nortriptyline may produce fewer anticholinergic adverse effects.1

Other antidepressants (e.g. selective serotonin reuptake inhibitors) have very limited evidence of analgesic efficacy and should not be used as analgesics.1

Duloxetine is unique among antidepressants in that it elevates the levels of three neurotransmitters (norepinephrine, serotonin, and dopamine); most other SSRI-type antidepressants are selective for serotonin (and sometimes norepinephrine). Duloxetine has been shown to be effective for the treatment of neuropathic pain and also disorders such as osteoarthritis and low back pain.1

Anti-epileptics

Adverse effects and the need for blood-monitoring limit the use of older anti-epileptic drugs in older people.14 Dose adjustment of gabapentin and pregabalin is required in patients with renal impairment.1

Combination therapy

Combination therapy (i.e. using different classes of analgesic drugs together) may provide greater pain relief through synergistic action, with fewer side-effects, compared with higher doses of a single medicine.2

Topical therapies

Focal or localised neuropathic pain may be treated with topical lidocaine and/or capsaicin (especially if there is a concern about side-effects with systemic drugs). NSAIDs may be suitable for non-neuropathic pain, particularly if pain is localised and not deep in origin (e.g. within a joint).1

Interventional therapies

Interventional approaches in the management of chronic or intractable pain include a variety of neural blocks and minimally invasive procedures, used either independently or in conjunction with other types of treatment. The main findings (see Box 2, below) were:1

  • intra-articular (IA) corticosteroid injections in knee osteoarthritis are effective in relieving pain in the short term with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is also effective in knee pain, with few systemic adverse effects, and it should be considered in patients intolerant to systemic therapy. It has a slower onset of action than IA steroids but the effects appear to last longer
  • epidural corticosteroid injections for spinal stenosis in older patients may be appropriate but evidence for their efficacy in radicular pain or sciatica is less convincing
  • epidural adhesiolysis for spinal stenosis and radicular symptoms may benefit older adults. The evidence for facet joint interventions in all age groups is mixed, although there is some support for radiofrequency denervation of the medial branch nerves in appropriately selected patients
  • there is weak evidence for sympathectomy for neuropathic pain in the older population. In older persons, a nerve block using a combination of local anaesthetic and corticosteroid is effective in acute herpes zoster and post-herpetic neuralgia. Botulinum toxin may also be beneficial for use in these patients
  • microvascular decompression is the treatment of choice for trigeminal neuralgia in healthy patients, and percutaneous procedures are indicated for elderly patients with high comorbidity
  • current evidence for vertebroplasty and kyphoplasty in the treatment of painful vertebral fractures is conflicting and no conclusion could be drawn
  • no studies of spinal cord stimulation specifically targeting the older population exist, but randomised controlled trials in mixed-aged groups (including people aged over 65 years), support its use in selected patients with:
    • failed back surgical syndrome
    • complex regional pain syndrome
    • neuropathic and ischaemic pain.

Box 2: Summary of interventional recommendations1

IA corticosteroid injections

  • effective in relieving pain in the short term
  • few complications and/or joint damage.

IA hyaluronic acid

  • effective with few systemic adverse effects
  • should be considered in patients intolerant to systemic therapy
  • has a slower onset of action than IA steroids but the effects appear to last longer.

Epidural corticosteroid injections

  • may be appropriate for spinal stenosis
  • use for radicular pain or sciatica is less convincing.

Epidural adhesiolysis

  • may be beneficial for spinal stenosis and radicular symptoms.

Sympathectomy

  • weak evidence for use in neuropathic pain.

Nerve blocks (combination of local anaesthetic and corticosteroid or botulinum toxin)

  • acute herpes zoster and post-herpetic neuralgia (see main text for further details).

Microvascular decompression

  • trigeminal neuralgia in healthy patients:
    • percutaneous procedures are indicated for elderly patients with high co-morbidity.
  • IA=intra-articular

Other strategies

For a summary of other strategies, see Box 3 and text below.

Psychological interventions

There is plenty of evidence to support the successful use of psychological interventions. Approaches such as cognitive behavioural therapy (CBT) or behavioural therapy may be effective in decreasing chronic pain and improving disability and mood in adults. However, in the few studies that have focused on older adults, the sample sizes were very small. There is a little evidence supporting the use of CBT for people in care homes and there is limited evidence that biofeedback training, relaxation, mindfulness, meditation, and enhancing emotion regulation may be beneficial for persistent pain in older people.1 Clearly, there is a need for more research in this area.

Physiotherapy and occupational therapy

Pain is known to be is a risk factor for falls in the older person, so it is important to note that the guideline advocates programmes offering people strengthening, flexibility, and endurance activities, which:1

  • increase physical activity
  • improve function
  • alleviate pain.

The exact type of exercise is probably less important; exercise needs to be tailored to the functional level of the individual. Balance exercises can be incorporated successfully into an exercise programme. Motivation to exercise is a factor to be borne in mind and barriers must be addressed.1

Assistive devices

A wide variety of devices designed to assist in activities of daily living are available; however most studies are descriptive in nature and very few have considered these devices in relation to pain reduction in older people.1

Use of assistive devices may:1

  • support community living
  • reduce:
  • functional decline
  • care costs.

Self-management

Self-management approaches include:1

  • relaxation
  • coping strategies
  • exercise
  • adaptations to activities
  • education about pain and its effects.

These techniques and practices are promoted for all aspects of care and should be considered in conjunction with other methods of pain management. All healthcare professionals who manage pain should be able to educate and support patients in self-management techniques.2 Some useful resources for patients and carers can be found at: www.webmd.boots.com/pain-management/guide/chronic-pain

Self-management programmes, with mechanisms for longer-term support and maintenance, may have some benefit but cannot yet be recommended to decrease pain and increase function when delivered in isolation, without ongoing support.1

Complementary therapies

There is limited evidence to support the use of complementary therapies, such as transcutaneous electrical stimulation (TENS), massage, and reflexology with older adults. The available evidence is generally weak and based upon small-scale studies without proper use of controls or randomisation procedures. Limited evidence was offered on the use of acupuncture.1

Box 3: Summary of other strategies1

CBT or behavioural therapy

  • some small studies are promising.

Biofeedback training, relaxation, mindfulness, meditation, and enhancing emotion regulation

  • some evidence in small-scale studies.

Physiotherapy and occupational therapy

  • exercise should be tailored to the functional level of the individual
  • balance exercises can be incorporated successfully into a programme.

Assistive devices

  • may:
    • support community living
    • reduce functional decline and care costs.

Self-management

  • individuals with pain must have ongoing support with their self-management.

TENS, massage and reflexology

  • some weak evidence of effectiveness.
  • CBT=cognitive behavioural therapy; TENS=transcutaneous electrical stimulation

Conclusion

The guidance focuses on the management of persistent pain in older people. Despite an extensive search, the guideline group identified only a minimal number of studies specifically relating to the management of pain in older people, and it was necessary to extrapolate from studies that had recruited a younger population, some of which included people over the age of 65 years. The guideline has exposed this lack of evidence for many types of treatment in a population where there is an ever-increasing number of older people.

The guideline provides clear recommendations for GPs and other healthcare practitioners on what to use in practice for the management of pain in older adults. The best evidence is presented and where there are gaps in the literature, this is highlighted.

Acknowledgements

The authors wish to acknowledge all the contributors to the pain management guideline,1 along with the reviewers, and thank the BPS and BGS for their support in developing it.

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
  • This guideline will be useful for commissioners in balancing the evidence (and lack of) for pharmacotherapies that can be included in local formularies:
    • these formularies should identify drugs of low acquisition cost, where available and suitable, and also list the licensed indications for their use in chronic pain
  • Commissioners could:
    • with NHS England, commission targeted medication reviews from community pharmacy to identify possible interactions or side-effects from the use of analgesic drugs in older people and monitor compliance
    • in conjunction with specialists in pain control and care of the elderly physicians, produce local algorithms for the use of pharmacotherapies, or identify when other interventions or referral to specialist care (e.g. pain clinics) are appropriate
  • When designing care plans for the 2% of adults most at risk of admission (as defined in the avoiding emergency admissions DES [in England]), GPs should consider escalation strategies for pain control where this is a major factor.
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  2. British Pain Society website. www.britishpainsociety.org (accessed 11 March 2014).
  3. British Geriatrics Society website. www.bgs.org.uk (accessed 11 March 2014).
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