Some people think that pain is natural with aging, or that when older people are not clear in explaining the cause or nature of their pain that they are "just complaining." Both of these views are wrong. There is almost always a real problem behind pain.
Arthritis is said to be the most common cause of pain in people over the age of 65. Circulatory problems, shingles, and other types of nerve damage, certain bowel diseases, and cancer are other common reasons for pain in older people.
Muscle pain is also quite common. Conditions that contribute to muscle pain in older people are fibromyalgia (especially in older women) and myofascial pain (which can result from trauma, nerve damage, and arthritis). These conditions are treated differently than other types of pain, and may get better without taking any medicine at all (that is, they may be best treated with physical therapy).
Pain can lead to other problems such as losing the ability to move around and do everyday activities. The sufferer may have trouble sleeping, experience "bad moods," and develop a poor self-image. In addition, people with pain often become anxious or depressed. They may be at greater risk for falls, weight loss, poor concentration, and difficulties with relationships.
On the positive side, most pain can improve with treatment that usually consists of a combination of medicine and non-medicine strategies. Treatments such as physical therapy, massage, application of heat and/or cold, exercise, and relaxation may be tried first. If these treatments are not successful alone, pain pills should be prescribed along with them and the person closely observed for side effects. Since all medicines have side effects, pain pills should be prescribed with care.
Non-Medication Strategies for Pain Relief
There are a number of ways to control pain without medicines. These include the following:
- Physical therapy, such as exercise, muscle stretching and strengthening, as well as heat, cold, and massage
- TENS (transcutaneous electrical nerve stimulation)
- Biofeedback
- Hypnosis
- Medicine
Often these strategies alone will relieve pain and the use of pain medicine can sometimes be avoided. If your doctor prescribes a medicine for pain, you should ask him or her whether other treatments are also available.
Medicines for Pain Relief
The medicines used to relieve pain are called analgesics. There are many types of analgesics:
- Aspirin, MotrinTM and AdvilTM are examples of medicines called non-steroidal anti-inflammatory drugs (NSAIDs). These medicines are often used to relieve arthritis pain and, while effective, most of them can also cause unwanted side effects, such as gastrointestinal bleeding, if taken at high doses for long periods of time
- Newer arthritic medicines called COX-2 drugs may be less harmful to the gastrointestinal tract, but like the other NSAIDs, they can be harmful to the kidneys and may elevate blood pressure
- Another type of arthritis medicine, called non-acetylated salicylates (e.g., DisalcidTM, TrilisateTM), is relatively easy on the stomach and generally does not harm the kidneys or elevate the blood pressure
- These medicines are worth discussing with your doctor
Strong pain medicines called opioids (narcotics) may be very effective in treating more severe types of pain, but they also have a variety of side effects. Examples of opioids include VicodinTM, PercosetTM, and morphine. Some opioids can be given via a patch applied to the skin every three days. Side effects of these types of medicine include tiredness, constipation, and confusion. These side effects may be treated by decreasing the dose of the medicine or by treating the side effect directly, such as by adding high fiber foods and exercise to treat constipation.
Opioids can sometimes be habit forming if used over a long period of time, but this does not occur very often. It is more important to treat the pain than to withhold medicine because of fear of causing addiction.
Believe the person you are caring for. If people with pain think that others do not believe them, they become upset and may stop reporting their pain accurately. This makes controlling the pain more difficult. People with pain are the only ones who know how much pain they are feeling. Pain is whatever a person says it is and exists whenever he or she says it does.
Every person has the right to good pain control. Your job as a caregiver is to make sure that good pain control is provided. Tell the doctor or nurse if pain does not lessen with treatment and ask the doctor to try new treatments until the pain is controlled. It is important to also recognize that while most pain can improve with treatment, complete pain relief may not be possible in every case.
Your goals are to:
Call the doctor or nurse immediately or go to the emergency room if any of the following symptoms occur
(A good rule of thumb is that all pain deserves to be treated, so inform the doctor or nurse of any pain so that the patient does not suffer needlessly.)
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There is a sudden change in the ability to walk or carry out other important activities because of pain.
Sudden changes in activity level often mean that the person is having significant pain and that the condition causing the pain has changed. Sometimes people can break a hip without having fallen. The only way to determine whether this has occurred is to do an x-ray.
On the other hand, the confused older person may become frightened because of pain, and because of this fear, he or she may refuse to walk or move even though there is nothing serious causing the pain. The best way to sort out this sometimes complicated situation is for the person with pain to be evaluated by a medical professional.
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There is new pain that is severe.
Whenever this occurs, seek help immediately.
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There is new pain that is not severe, but it is causing the person significant distress.
The new occurrence of chest discomfort, for example, may indicate a heart attack. Often this pain is not severe. The person may be experiencing a sensation of heaviness or pressure.
Another example is abdominal pain. If the person has abdominal pain along with fever or vomiting, help should be sought immediately. There are many other pain situations that warrant immediate medical attention. If you are concerned about pain, call the doctor.
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There is talk about not wanting to live any more.
When pain is severe and lasts a long time (especially certain kinds of pain related to nerve damage), older people may want to escape from the pain. If they feel that help is not available, they may talk about suicide. This should be taken very seriously. If older people have thoughts about wanting to harm themselves, this should be considered an emergency.
Call the doctor or nurse during office hours to discuss the following problems
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No relief after taking pain medication as prescribed
The doctor may change the amount of medicine, how often it is taken, or the type of pain medicine, or he or she might want to do a physical examination.
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Some pain relief, but there is still a lot of pain one or two days after starting the medicine
In this case, the doctor or nurse needs to reevaluate the amount or type of pain medicine prescribed.
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New or different pain
New pain may need to be evaluated before the next regularly scheduled office visit. If in doubt, call and speak with the doctor or nurse..
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Adverse side effects of pain medications
If the patient cannot tolerate a particular pain medicine, let the doctor know so that something different can be prescribed. Don't wait until the next scheduled appointment. There is no need to suffer pain when it can be treated.
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Changes in sleep
Getting good sleep is very important in the treatment of pain. If a person does not sleep well, it becomes more difficult for him or her to tolerate pain. Many things can cause difficulty sleeping, for example, depression, anxiety, sleep apnea, certain medicines, or the pain itself. The treatment depends upon the cause. If the person you are caring for is having difficulty sleeping, be sure to let the doctor know so that this important problem can be addressed.
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Difficulty coping with pain
Pain that persists for a long time may take a toll on a person's emotions. He or she may become anxious, depressed, or irritable. These problems should be taken very seriously. They usually respond well to treatment with medicines and other strategies.
Know the answers to the following questions before calling the doctor
Describe the pain
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How long has the pain been a problem?
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Is it a new pain or has it happened before?
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Where is it located? Is it in more than one area? If so, which location is most bothersome? Does it move from one place to another?
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How severe is the pain? Ask the person whether it is mild, moderate, severe, or unbearable.
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Is the pain sharp and stabbing, dull and aching, burning, or does it feel like an electric shock?
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Is there any numbness, tingling, or new weakness in the pain area?
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How does the pain interfere with doing normal activities? What activities or conditions make the pain worse?
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What has been tried to relieve the pain?
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What medicines are being taken? Are the medicines taken at set times or just when the person you are caring for needs them? Is he or she allergic or sensitive to any pain medicine?
Here is an example of what you might say when calling for help:
"This is Margaret Smith, John Smith's daughter. My father is a patient of Dr. Troy. This morning he refused to get out of bed because his leg hurt so badly near the hip, and it hurts even if he tries to move just a little in bed. He said his pain is sharp. At 6:00 a.m. he took two Percocet
TM but didn't feel any better. The next time for his medicine isn't until noon. We tried a heating pad, but it didn't help."
Evaluate pain
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Ask about the pain.
The best way to find out if a person is in pain is to ask. No medical test can give you this information. It is also very important to be sure that the older person knows that you believe him or her.
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Listen for words other than "pain".
Older people may use different words to describe their pain, such as "discomfort" or "soreness" or "ache" or "heaviness."
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Look for behavior or body language that looks like a response to pain.
An older person may be unwilling to report pain or be unable to communicate about pain in words. Behaviors or body language to look for include facial expressions such as the following:
Tears
Eyes that are closed tightly
Knitted eyebrows
Wrinkled forehead (grimacing)
Groaning when moved
Clenched fists
A stiffened upper or lower body that is held rigidly and moved slowly
Decreased activity level
Trouble sleeping
Poor appetite
Other signs may include rubbing certain parts of the body, slouched or bent posture, avoiding sitting or standing.
Everyone expresses pain differently. As the caregiver you are in the best position to know when the person you are caring for is in pain because you know him or her better than anyone.
Keeping track of pain is difficult. Severity of pain can change over time or it can come and go. Sometimes it can be difficult to get information about the pain from the person who has it. And sometimes it can be hard to tell the difference between old pain and new pain. It is important that you do the best that you can and keep a record of the pain.
Improve chances for obtaining good pain relief
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Use pain medicines as prescribed.
If the prescription says to take the medicine at certain times or at certain time intervals (for example, every six hours), make sure the person you are caring for does so. Do not wait until the pain comes back to give the medicine. This will cause needless suffering. One of the important ways that pain medicine works is that it helps to prevent episodes of severe pain. In order to do this, there has to be a certain amount of medicine in the blood. This is why the doctor prescribes taking the medicine at regular intervals-to be sure that the blood level stays high enough.
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Don't withhold medicine for fear of addiction. Addiction is very rare in patients who have real pain and who take pain medicine under a doctor's supervision. Also, do not withhold medicine for fear the medicine will become less effective over time. The amount or type of medicine can always be changed.
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Insist on good pain control.
Pain generally tends to be under-treated. Make sure the doctor knows there is a pain problem, and let him or her know if treatment is not meeting the needs of the person you are caring for.
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Ask about pain clinics. If your doctor cannot control the pain, ask for a referral to a pain clinic that has a team of people (doctors, nurses, physical and occupational therapists, psychologists) that specialize in pain treatment. Universities and large hospitals often have these types of clinics.
Help to reduce pain
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Use warm showers, baths, hot water bottles, or warm washcloths.
Heat relaxes muscles; this can help reduce pain and give a sense of comfort. Do not set heating pads on high because they can burn the skin. Also, try massaging sore spots, such as neck and shoulders. Check with the doctor about how long to apply heat since prolonged exposure to heat can cause tissue damage.
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Use cool cloths. Cooling the skin and muscles can soothe pain, especially pain that comes from inflammation or swelling. For example, many people find that using a cool washcloth on their forehead reduces pain when they have a headache. Check with the doctor about how long to apply cold since prolonged exposure to cold can cause tissue damage.
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Position the person carefully with pillows and soft seat cushions
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Encourage relaxation.
Breathing slowly and quietly helps the mind and body to relax and helps decrease pain. Simple relaxation methods can be learned from books on relaxation techniques which are available at most bookstores. Relaxation audiotapes can also be purchased through most bookstores.
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Provide pleasant activities.
Being active takes the mind off the pain. Distractions such as pleasant visits with friends and grandchildren should be encouraged. Watching television, reading, and listening to music may also decrease a person's awareness of pain.
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Avoid stressful events when possible.
Emotional stress and anxiety increase pain. Try to minimize these types of situations.
Problems You Might Have Carrying Out Your Plan
Problem:
"If I tell the doctor about my pain she'll think I'm a complainer."
Response: It is the doctor and nurse's job to work out the best way to control pain. To do this, they rely on you to tell them about the pain of the person you are caring for. They can't do their job unless you do yours.
Problem:
"Of course she has aches and pains. She's old."
Response: Pain is not a normal part of growing old. Pain in older adults, just like pain in any other age group, is a signal that something is wrong. You and the person you are caring for need to talk about this with a doctor so the problem can be treated.
Problem:
"My father is confused. What he says doesn't make sense, so I can't tell whether he's in pain or not."
Response: Even when people are confused, oftentimes they can let you know when they are in pain. It may be helpful to look for changes in mood, activity level, body language, and facial expressions as discussed in the section above, "What You Can Do to Help.".
Problem:
"I'm afraid of addiction."
Response:It is very unusual for people who have pain to become addicted to pain medicines. They are taking the medicines for a good reason, to relieve their pain, not to "get high." People who have pain need to be treated, so concerns about addiction, in most cases, should not enter into the doctor's decision to prescribe these medicines.
There is a difference between addiction, which is a psychological craving for medicine, and physical dependence. People who need opioids (narcotics) for only a period of time may develop a physical dependence on the medicine, with uncomfortable symptoms, such as sweating, chills, and nausea, if the medicine is stopped suddenly. This is only a temporary situation that can be prevented by slowly reducing the medicine over a few days or a few weeks.
Think of Other Problems You Might Have Carrying Out Your Plan
What other problems could get in the way of doing the things suggested in this chapter? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out this plan?
You need to make plans for solving these problems. Use the four COPE problem-solving steps in the chapter on "How to Use the Eldercare at Home Book to Solve Caregiving Problems."
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Ask about pain regularly and keep notes. Adjusting pain medicines to fit each patient takes time so change may be slow. Keep the doctor or nurse informed about changes in pain.
What to Do If Your Plan Isn't Working
If, after a reasonable time, pain is still a problem, ask for a referral to a pain clinic. Relief from pain is possible in most cases. It is also important to recognize that most pain that has gone on for a long time cannot be totally relieved, but people can be taught how to live better lives with their pain. Remember that help is available, but persistence on your part is important in order to get the relief that the person you are caring for deserves.
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For additional information:
Agency for Healthcare Research and Quality
P.O. Box 8547
Silver Spring, MD 20907
800-358-9295
This clearinghouse provides health-related information in many areas, including pain
management.
Call to order free patient guides:
- "Understanding Acute Low Back Pain Problems" (No. 95-0644)
- "Pain Control After Surgery" (No. 92-0021)
- "Managing Cancer Pain" (No. 94-0595)
Arthritis Foundation
1330 W. Peachtree Street
Atlanta, GA 30309
1-800-283-7800
and
1-800-207-8633
Offers general and specific information, educational brochures, videotapes, and an
"online chat room" on AOL, among other services.
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THIS PAGE LAST UPDATED ON 4/07/04