Eldercare at Home: Pain
Caregiving How Tos
Understanding the Problem
Some people think that pain is natural with aging. Others may believe that older people are “just complaining” if they are not clear in explaining the cause or nature of their pain. Both of these views are wrong. Having pain is very common in older adults, but it is never normal. 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. Nerve damage, shingles, problems with circulation, certain bowel diseases, and cancer are other common reasons for pain in older people.
Muscle pain is also quite common. A condition called fibromyalgia can cause muscle pain especially in older women. Another condition called myofascial pain may result from trauma, nerve damage, and arthritis. These conditions are treated differently than other types of pain, and may be best treated with physical therapy without taking any medicine at all.
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," or 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 will improve with treatment that uses both medicine and non-medicine strategies. Treatments such as physical therapy, massage, heat and/or cold packs, exercise, and relaxation therapy may be tried first. If these treatments do not provide enough pain relief, pain pills, creams or patches may be prescribed as well. Since all medicines have side effects, the person should be closely observed for side effects.
Non-Medication Strategies for Pain Relief
There are a number of ways to help 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)
Often these strategies alone will relieve pain and the use of pain medicine may not be needed. If your doctor prescribes a medicine for pain, you should ask if other treatments are also available.
Medicines for Pain Relief
The medicines used to relieve pain are called analgesics. There are many types of analgesics: Acetaminophen is recommended as the safest type of pain reliever for long-term use which can be purchased at the store without a prescription. It is important to take no more than 4000mg of medicine in 24 hours to avoid possible liver damage and other side effects. Since many cold medicines and prescription pain pills also have acetaminophen as an ingredient, be sure to check the labels if you are giving an older person acetaminophen regularly.
- Aspirin, ibuprofen and naproxen are examples of medicines called non-steroidal anti-inflammatory drugs (NSAIDs) which are also available without a prescription. These medicines are often used to relieve arthritis pain but should not be used very long due to their unwanted side effects. Older adults are more likely to suffer side effects such as stomach ulcers, kidney problems and congestive heart failure. If NSAIDs must be used, older persons should use a proton pump inhibitor such as omeprazole for gastrointestinal protection.
- 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
- Topical NSAID or anesthetic pain creams and patches which are available by prescription only may be helpful for local pain. They are most helpful for specific joints or areas and generally do not help pain all over the body.
- Creams and patches which are available without a prescription, including capsaicin, methyl salicylate or menthol may also be effective for specific areas of the body. There are other medicines just for nerve pain which work by changing how the brain and nerves perceive pain signals from the body. These can be taken in addition to usual pain blockers, but may have side effects of confusion, sleepiness or low blood pressure. As always, the person taking the medicine should be watched closely for side effects.
- 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 hydrocodone, oxycodone, 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:
- Help evaluate and relieve pain
- Keep your doctor or nurse informed about pain levels and responses to pain treatments
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. However, certain situations are urgent while others which are not so severe can wait for a short period of time.
Call the doctor or nurse immediately or go to the emergency room if any of the following symptoms occur:
- 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, a confused older person may become frightened because of pain. 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.
- There is new pain that is severe.
Whenever this occurs, seek help immediately.
- There is new pain that is not severe, but it is causing the person significant distress.
New chest discomfort, for example, may be the first sign of 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 deserve immediate medical attention. If you are concerned about pain, call the doctor.
- There is talk about not wanting to live any more.
When pain is severe and lasts a long time, older people may want to escape from the pain. This is especially true with certain kinds of pain related to nerve damage. 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
- No relief after using pain medication as recommended
The doctor may suggest a change in the amount of medicine, how often it is used, or the type of pain medicine. He or she might want to talk to the person or do a physical examination to help figure out what should be done next.
- 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.
- 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.
- Side effects of pain medications
If the patient cannot tolerate a particular pain medicine, let the doctor know so that something different can be done. Don't wait until the next scheduled appointment. There is no need to suffer pain when it can be treated.
- 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 to tolerate pain. Many things can cause problems sleeping, such as depression, worry, stress, sleep apnea, certain medicines, or the pain itself. The treatment depends upon the cause. If the person you are caring for is having trouble sleeping, be sure to let the doctor know so that this important problem can be addressed.
- Trouble 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:
- Can you describe the pain?
- How long has the pain been a problem?
- Is it a new pain or has it happened before?
- 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?
- How severe is the pain? Ask the person whether it is mild, moderate, severe, or unbearable.
- What does the pain feel like? Is it sharp, stabbing, dull, aching, burning, or does it feel like an electric shock?
- Is there any numbness, tingling, or new weakness in the pain area?
- How does the pain change with doing normal activities? What activities or conditions make the pain worse?
- What makes the pain better?
- What medicines are being taken? Are the medicines taken at set times or just when the person you are caring for needs them? How do you tell when he or she 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 oxycodone 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."
- 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.
- 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" or “misery.”
- 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:
- 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
- Use pain medicines as recommended.
If the recommendation says to take the medicine at certain times (such as “one hour before exercise”) or at certain time intervals (such as “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.
- 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.
- 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.
- 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
- 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.
- 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.
- Position the person carefully with pillows and soft seat cushions
- 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.
- 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.
- 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
"If I tell the doctor about the pain she'll think I'm a complainer."
It is the doctor and nurse's job to work out the best way to control pain. To do this, they count 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.
"Of course she has aches and pains. She's old."
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.
"My father is confused. What he says doesn't make sense, so I can't tell whether he's in pain or not."
Even when people are confused, oftentimes they can still 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.".
"I'm afraid of addiction."
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. The person you are caring for might be worried and may need to be reassured that they do not need to worry about “becoming an addict.”
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 section? 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?
Ask about pain regularly and keep notes. It can be very useful to keep a diary which tracks what times pain happens, what the person is doing when the pain occurs, and how well the treatments work to relieve pain. Adjusting pain medicines to fit each persons 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.