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Pain is one of the most common complaints among older adults. Between 25 and 50% of older adults living at home, and 45 to 80% of those living in nursing homes, have significant pain. Most often, the pain is chronic or persistent, associated with chronic medical conditions such as arthritis or cancer.

Many older adults do not tell anyone about their pain or how severe it is. In some cases, they think–incorrectly–that pain is a consequence of aging that cannot be avoided or treated. Others ignore or deny the pain because they don’t want to accept what the pain may mean, eg, their condition is worsening or cancer is progressing. Some people try to ignore pain because they don’t want to be seen as troublesome or a burden. However, none of these is a good reason for living with persistent pain.

Persistent pain decreases quality of life in many ways. It affects us physically, socially, and psychologically. It can result in difficulty in performing activities of daily living, problems thinking, depression, anxiety, social isolation, loss of appetite, and sleep problems. It can indirectly affect balance and walking, increasing the risk of dangerous falls. Pain can also slow down or prevent rehabilitation, which is associated with loss of function and more dependence on others. Chronic pain may also cause people to seek relief in alcohol or illegal drugs, leading to the serious complications associated with substance abuse.

• Causes of Pain
• Assessment and Evaluation of Pain
• Pain Management
• Management of chronic pain without drugs
• Drug treatment
• Over-the-counter preparations
• Local treatments
• Narcotics
• Other medications
• Patient-controlled pain relief

The most common causes of persistent pain are arthritis, other muscle and bone conditions, and cancer. Shingles (herpes zoster), poor circulation, and inflammatory disease involving the blood vessels are some other specific pain syndromes that are known to especially affect older adults.

Pain is more than just a simple sensation. It is a very complex sensory experience that is influenced by memories, expectations, and emotions. Pain is transmitted by nerves that travel through the spinal cord. One type of pain response travels on a "fast track," relaying information directly to the brain about the physical location and type of pain (eg, sharp, severe, or sudden). A second slower track deals with the emotional qualities of pain. People have described such pain as "burning," "frightening," or "cruel." There is also a third nervous response that helps to lessen the pain sensation.

Pain is usually characterized as acute or chronic. Acute pain begins distinctly and lasts only a short time. This type of pain follows injury, burns, or surgery. Acute pain is usually associated with additional symptoms of stress, such as fast heart rate, sweating, or a sudden rise in blood pressure. In contrast, chronic pain lasts 3—6 months or longer. It is usually not accompanied by symptoms of stress, but can result in long-standing functional and psychological problems.

Pain is a very individual experience. It differs from person to person, even when the individuals have similar illnesses. Your health care provider will likely ask detailed questions about the type, characteristics, and severity of the pain. He or she will also want to know about anything that worsens or relieves the pain, as well as any physical or social limitations you are having because of the pain. There are no laboratory tests for pain. You and your caregivers are the only source of information about pain, and answering the questions as accurately and completely as possible will help your health care provider identify the source of pain and then treat the pain effectively.

Various rating scales have been developed to help us assess pain more accurately. You may be asked to rate your pain on a numerical scale, or match the level of your pain to specific written descriptions. For example, "Rate the pain from 1 to 10, with 10 being the worst pain imaginable." Your health care provider may even ask you to keep a "pain diary" to describe your pain on a day-to-day basis.

A psychological assessment may also be conducted. Most people with chronic pain have significant symptoms of depression or anxiety and may benefit dramatically from psychological or psychiatric support.

The physical examination will include a careful examination of the main site of the pain, and of any part of the body that may be a source of referred pain (pain in which the source of the pain is different from the area where the pain is felt). The muscles, bones, and joints will be examined carefully because they are common sources of pain in older adults. Other specific tests (eg, blood tests, X-rays, MRIs, etc) may be recommended as needed.

Of course, the above assessments are effective only when a person is mentally capable of answering questions. In people who have mental difficulties, body language such as facial expressions and restlessness or nervousness (agitation) are important behavioral cues that indicate pain (see Palliative Care and End of Life Issues).

Acute pain is generally controlled by treating the underlying disease and using short-term pain relievers. Chronic pain, however, usually requires several approaches, including various behavioral and coping strategies, in addition to pain relievers and possibly other drugs. These combination techniques usually result in more effective pain control, with less use of medications that can cause side effects in older adults.

Pain management strategies that do not use drugs may provide some level of pain relief. These techniques include the following:

• transcutaneous electrical nerve stimulation (TENS)
• physical therapy
• biofeedback and hypnosis
• distraction techniques

Each of these techniques may be quite effective in individual patients.

TENS has been used for a variety of chronic pain conditions in older adults. These include painful nerves caused by diabetes, shoulder pain or bursitis, and fractured ribs. Although TENS does not work for everyone, some people experience good relief of symptoms. This effectiveness may wear off after a few months, although some people have had years of pain relief. Care must be taken to avoid skin irritation and possible burns from the electrodes.

Physical methods such as heat, cold, massage, and rubs applied to the skin can help manage pain in muscles, bones, and joints. Many of these methods relax tense muscles and feel soothing. Older adults can often perform these therapies themselves, giving them and their families a sense of control over the symptoms and treatment. However, caution must be exercised with the prolonged use of heat or cold, to avoid burns and other skin injury. Heat or cold packs should only be applied for 15-20 minutes at a time. Some people alternate heat with cold to obtain relief. Topical rubs containing menthol, salicylate, or even an extract of hot peppers (capsaicin) give a sensation of heat or cold that works very well for some people (see Local treatments).

Biofeedback, relaxation, and hypnosis may be effective in controlling pain, although they are not as useful in people with memory difficulties. These techniques require the skills of a trained psychologist or therapist.

A variety of distractions can serve to decrease our perception of pain. Many people find comfort in music, meditation, or prayer. Inactivity and inability to move around may contribute to depression and greater pain. Staying involved in activities, exercise, and recreation as much as possible can make you feel better and take your mind off the pain. A sense of humor, the companionship of a pet, and visits by family and friends can also play significant roles in pain relief.

Various over-the-counter (OTC) and prescription products are available to treat chronic pain. The goal of drug treatment is not only to remove the pain, but also to improve function and quality of life. This means it is important to balance the risks and benefits of drug treatment. Drugs should be reserved for moderate to severe pain that is unrelieved by other approaches.

Mild to moderate pain is commonly treated with acetaminophen (eg, Tylenol^®). Acetaminophen is especially useful for pain from muscles, bones, and joints. No more than 12 regular-strength (or 8 extra-strength) tablets or capsules should be taken during any 24-hour period because of the risk of liver damage. If you have been diagnosed with liver problems, you should consult your health care provider before taking acetaminophen preparations. It might still be okay to take acetaminophen but at a reduced dosage. People who drink alcoholic beverages regularly should not take more that 6 grams of acetaminophen in 24 hours. Remember also that acetaminophen is commonly included in many OTC cold and flu products.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are available both OTC and by prescription. This class of drugs includes aspirin, ibuprofen, and naproxen sodium. NSAIDs provide specific relief for inflammatory conditions that stimulate pain (eg, swollen muscles and joints). They relieve mild to moderate pain when used alone, and often work well in combination with narcotic pain relievers. NSAIDs may be especially helpful in managing pain associated with cancer affecting the bone.

NSAIDs are not generally habit-forming, but they can result in various side effects, including stomach irritation (and possibly ulcers), kidney problems, and the tendency to cause bleeding. Women older than 85 years are at greatest risk of bleeding ulcers.

Topical or local drug treatment can effectively relieve pain in some conditions. For example, topical preparations (meaning applied to a body surface, such as the skin), including capsaicin creams, ketamine gel, or lidocaine patches, may be effective for some types of nerve pain. Local injection of corticosteroids can relieve pain that is in a particular joint, tendon, or muscle. These localized treatments avoid the side effects that can develop when drugs circulate throughout the body.

Narcotics may be needed to provide adequate relief for moderate to severe pain, or for pain that requires chronic treatment. Narcotic medications act on the nervous system to decrease the perception of pain. Narcotics relieve many types of pain, although they appear to be less effective in managing chronic pain due to nerve irritation. Compared with younger people, older adults are more sensitive to the pain-relieving properties of these drugs.

When administered properly and under medical supervision, narcotics remain the best understood and most predictable medications for severe or chronic pain. However, side effects include fatigue, sleepiness, memory disturbances, confusion, nausea, vomiting, and constipation. Many of these side effects decrease over time except constipation. Anyone using narcotics for chronic pain should also be using laxatives. Adequate fluid intake and exercise can also help alleviate constipation. (See also Palliative Care and End-of-Life Issues.)

One of the most feared side effects of narcotics is addiction from habitual use. Because of this, many older adults avoid narcotics, and some physicians do not prescribe them. However, it is very rare for older adults who have chronic pain to become truly addicted to narcotics prescribed by their physicians. True addiction is psychological dependence, in which the addict compulsively seeks the drug without regard to negative social, physical, and financial consequences. In most cases of pain relief, once the pain goes away, people no longer want the drugs. In fact, in one study in which over 12,000 medical records were examined, only four cases of narcotic dependency produced by medical treatment were found.

Although psychological dependence is rare, people can become physically dependent on narcotics. In this case, abruptly stopping the drug results in symptoms of withdrawal. These symptoms can be avoided by decreasing the drug dosage gradually over days to weeks. Fear of physical dependence is not a good reason to avoid the benefits provided by narcotics in chronic treatment of pain.

Some types of pain caused by nerve irritation may respond to antidepressants or antiseizure medications. This includes the nerve irritation produced by shingles (herpes zoster), diabetes, and stroke. Treating any underlying depression or mood disorders may also improve other pain management strategies. Antidepressants or mild sedatives may also help a person have a good night’s sleep. Chronic pain is an exhausting experience, and most people cope better if they are able to get enough sleep. (See also Depression.)

Corticosteroids may also be useful for treating pain associated with swelling, inflammation, and nerve irritation. They may also increase appetite and improve energy. However, even short-term use can have many side effects, including psychosis, fluid retention (ie, feeling bloated), hair loss, skin problems, high blood sugar, and suppression of the immune system.

Patient-controlled pain relief has proved to be an effective strategy in managing chronic pain. In this approach, the person has a handheld pump or trigger that lets him or her control the dose and frequency (within reason) of pain medication that is being given through an intravenous line. In addition to the pain relief, the person has a psychological benefit because this technique allows him or her to be more in control of the pain by balancing individual pain tolerance and side effects more effectively.