The prevalence of chronic pain in older persons is higher than it is in other age groups. Although prevalence estimates vary from study to study depending on method used and population under investigation, chronic pain has been estimated to affect as many as 76% of older persons who live independently and as many as 93% of those who reside in long-term care facilities (Abdulla et al., 2013). Despite its high prevalence, pain is often undertreated in older adults and such undertreatment is especially significant among older persons with dementia (e.g., Balfour & O’Rourke, 2003; Cleeland et al., 1994; de Souto Barreto, Lapeyre-Mestre, Vellas, & Rolland, 2013; Ferrell et al., 2001).
There are several factors that contribute to the undertreatment of pain in older persons. Older adults, for example, may be more stoic when it comes to reporting pain (Yong, Gibson, David, & Helme, 2001). Moreover, it has been suggested that societal beliefs and attitudes contribute to pain undertreatment (e.g., Herr & Garand, 2001). That is, many consider pain to be “a normal part of growing old.” Viewing pain as a normal part of aging may lead health professionals to be less likely to treat pain thoroughly in older patients and older patients may be less likely to seek pain management than are their younger counterparts. But pain is not a normal part of the aging process. As such, pain should be treated irrespective of a person’s age. Further, among seniors with severe dementia, there is the added difficulty that there can be serious limitations in ability to self-report pain related to the cognitive and language impairments that accompany the dementing condition. As such, pain problems often go undetected in this population. In fact, among patients with dementia, behavioral disturbance due to pain can be misattributed to a psychiatric problem and is often treated with psychotropic rather than analgesic medication (e.g., Balfour & O’Rourke, 2003; Cipher, Clifford, & Roper, 2006). This is unfortunate because use of psychotropic medications may hasten death in this population (e.g., Ballard et al., 2009).
Hadjistavropoulos et al. (2007) provide detailed recommendations for the pain assessment of the older adult. In summary, a thorough pain assessment is a comprehensive process that should not be limited to evaluations of pain intensity. Instead, patient emotional/personality/social functioning and coping resources should also be evaluated along with reported functional limitations as well as cognitive and behavioural responses to pain. Psychological assessment results should be integrated with a complete clinical history and the findings of medical and functional examinations. As with any type of psychological assessment of older persons, it is important to select clinical tools that have been appropriately validated with this population. For clinicians, interested in a brief screening battery suitable for cognitively intact older persons, Hadjistavropoulos et al. (2007) recommended use of the Brief Pain Inventory (Cleeland & Ryan, 1994) combined with the short form of the McGill Pain Questionnaire (Melzack, 1975). The combination of these two tools would allow for an evaluation of pain intensity, self-reported interference with function, pain location, medication use, perceived relief and measurement of the sensory and affective qualities of the pain experience.
Given the serious communication limitations of people with severe dementia, psychometric testing is often unfeasible and recent research has led to a proliferation of observational pain assessment tools, some of which have strong psychometric properties (see Herr, Bursch, Miller & Swafford, 2010; Lints-Martindale, Hadjistavropoulos, Lix, & Thorpe, 2012; Zwakhalen, Hamers, Abu-Saad, & Berger, 2006). Research has demonstrated that regular observational pain assessments of seniors with dementia can have considerable clinical benefits (Fuchs-Lacelle, Hadjistavropoulos, & Lix, 2008; Hadjistavropoulos, Kaasalainen, Williams, & Zacharias, in press). For more specific recommendations for the patient with dementia, the reader is referred to Hadjistavropoulos, Dever-Fitzgerald and Marchildon (2010).
Generally speaking, it is widely recognized that the best approach to managing chronic pain is interdisciplinary. From a psychological standpoint, cognitive behavioral therapy (CBT) procedures have been used with some success in the chronic pain management of the older adult but positive findings are sometimes limited to specific domains of functioning such as beliefs about pain (e.g., Green, Hadjistavropoulos, Hadjistavropoulos, Martin, & Sharpe, 2009; Waters, Woodward, & Keefe, 2005). In a meta-analytic investigation focusing on CBT for older persons with pain, Lund, Nordhus and Pallesen (2009) found a moderate overall effect size and demonstrated benefits on self-reported pain but not on depression, medication use and physical function. More research investigating the longer-term efficacy of CBT with this population is needed. In recent years, some promising findings are beginning to emerge with mindfulness-based (e.g., Morone, Greco, & Weiner, 2008; Morone, Lynch, Greco, Tindle, & Weiner, 2008) as well as with acceptance and commitment approaches to pain management (McCracken & Jones, 2012).
The American Geriatrics Society (2009) has outlined specific recommendations regarding the pharmacological pain management of the older adult. The interested reader is referred to the American Geriatrics Society Pharmacological Management of Persistent Pain in Older Persons for more information.
Written by Thomas Hadjistavropoulos, Ph.D., ABPP, University of Regina, Canada
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Look at the extensive assessment database of geriatric measures from the University of Alabama’s Alabama Research Institute on Aging! Register for access to the database HERE.
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