Pain Management 2018-02-11T19:41:50+00:00

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

GENERAL

Backman, C.L. (2006). Psychosocial aspects in the management of arthritis pain. Arthritis Research & Therapy, 8, 221-228. Available online.

Backman, C.L. (2006). Psychosocial aspects in the management of arthritis pain. Arthritis Research & Therapy, 8, 221-228.  Available online.

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Balfour, J. E., & O’Rourke, N. (2003). Older adults with Alzheimer Disease, comorbid arthritis and prescription of psychotropic medications. Pain Research and Management, 8(4), 198-204.

Balfour, J. E., & O’Rourke, N. (2003). Older adults with Alzheimer Disease, comorbid arthritis and prescription of psychotropic medications. Pain Research and Management, 8(4), 198-204.

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Cipher, D. J., Clifford, P. A., & Roper, K. D. (2006). Behavioral manifestations of pain in the demented elderly. Journal of the American Medical Directors Association, 7(6), 355-365. doi: 10.1016/j.jamda.2005.11.012

Cipher, D. J., Clifford, P. A., & Roper, K. D. (2006). Behavioral manifestations of pain in the demented elderly. Journal of the American Medical Directors Association, 7(6), 355-365. doi: 10.1016/j.jamda.2005.11.012

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Deane, G., & Smith, H.S. (2008). Overview of Pain Management in Older Persons. Clinics in Geriatric Medicine, 24(2), 185–201.

Deane, G., & Smith, H.S. (2008). Overview of Pain Management in Older Persons. Clinics in Geriatric Medicine, 24(2), 185–201.

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Herr, K. (2010). Pain in the Older Adult: An Imperative Across All Health Care Settings. Pain Management Nursing, 11(2) Supplement, S1–S10.

Herr, K. (2010). Pain in the Older Adult: An Imperative Across All Health Care Settings. Pain Management Nursing,  11(2) Supplement, S1–S10.

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ASSESSMENT

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.

Bjoro, K., & Herr, K. (2008). Assessment of Pain in the Nonverbal or Cognitively Impaired Older Adult. Clinics in Geriatric Medicine, 24(2), 237–262.

Bjoro, K., & Herr, K. (2008). Assessment of Pain in the Nonverbal or Cognitively Impaired Older Adult.  Clinics in Geriatric Medicine,  24(2), 237–262.

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Ferrell, B.A., Stein, W.M., & Beck, J.C. (2000). The Geriatric Pain Measure: Validity, Reliability and Factor Analysis. Journal of the American Geriatrics Society, 48(2), 1669-73.

Ferrell, B.A., Stein, W.M., & Beck, J.C. (2000). The Geriatric Pain Measure: Validity, Reliability and Factor Analysis. Journal of the American Geriatrics Society, 48(2), 1669-73.

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Fuchs-Lacelle, S. & Hadjistavropoulos, T. (2004). Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Management Nursing, 5(1), 37-49. Click here for the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PASLAC).

Fuchs-Lacelle, S. & Hadjistavropoulos, T. (2004). Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Management Nursing, 5(1), 37-49.  Click here for the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PASLAC).

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Fuchs-Lacelle, S., Hadjistavropoulos, T., & Lix, L. (2008). Pain assessment as intervention: A study of older adults with severe dementia. Clinical Journal of Pain, 24(8), 697-707.

Fuchs-Lacelle, S., Hadjistavropoulos, T., & Lix, L. (2008). Pain assessment as intervention: A study of older adults with severe dementia. Clinical Journal of Pain, 24(8), 697-707.

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Hadjistavropoulos, T., Dever Fitzgerald, T., & Marchildon, G. (2010). Practice guidelines for assessing pain in older persons who reside in long-term care facilities. Physiotherapy Canada, 62(2), 104-113. doi:10.3138/physio.62.2.104

Hadjistavropoulos, T., Dever Fitzgerald, T., & Marchildon, G. (2010). Practice guidelines for assessing pain in older persons who reside in long-term care facilities. Physiotherapy Canada, 62(2), 104-113. doi:10.3138/physio.62.2.104

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Hadjistavropoulos, T., Herr, K., Turk, D.C., Fine, P.G., Dworkin, R.H., Helme, R., Jackson, K., Parmelee, P.A., Rudy, T.E., Beattie, B. L. Chibnall, J. T., Craig, K.D., Ferrell, B., Ferrell, B., Fillingim, R. B., Gagliese, L., Gallagher, R., Gibson, S. G., Harisson, L., Katz, B. Keefe, F., Lieber, S. J., Lussier, D., Schmader, K.E., Tait, R.C., Weiner, D.K., Williams, J. (2007). An interdisciplinary expert consensus statement on assessment of pain in older persons. Clinical Journal of Pain, 23, S1-S43.

Hadjistavropoulos, T., Herr, K., Turk, D.C., Fine, P.G., Dworkin, R.H., Helme, R., Jackson, K., Parmelee, P.A., Rudy, T.E., Beattie, B. L. Chibnall, J. T., Craig, K.D., Ferrell, B., Ferrell, B., Fillingim, R. B., Gagliese, L., Gallagher, R., Gibson, S. G., Harisson, L., Katz, B. Keefe, F., Lieber, S. J., Lussier, D., Schmader, K.E., Tait, R.C., Weiner, D.K., Williams, J. (2007). An interdisciplinary expert consensus statement on assessment of pain in older persons. Clinical Journal of Pain, 23, S1-S43.

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Hadjistavropoulos, T., Kaasalainen, S., Williams, J., & Zacharias, R. (in press). Improving pain assessment practices and outcomes in long-term care facilities: A mixed methods investigation. Pain Management Nursing.

Hadjistavropoulos, T., Kaasalainen, S., Williams, J., & Zacharias, R. (in press). Improving pain assessment practices and outcomes in long-term care facilities: A mixed methods investigation. Pain Management Nursing.

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Herr, K., & Garand, L. (2001). Assessment and measurement of pain in older adults. Clinics in Geriatric Medicine, 17(3), 457-478. doi: 10.1016/S0749-0690(05)70080-X

Herr, K., & Garand, L. (2001). Assessment and measurement of pain in older adults. Clinics in Geriatric Medicine, 17(3), 457-478. doi: 10.1016/S0749-0690(05)70080-X

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Lichtenberg, P.A. (Ed.) (2010). Handbook of assessment in clinical gerontology (2nd edition). Burlington, MA: Academic Press.

Lichtenberg, P.A. (Ed.) (2010). Handbook of assessment in clinical gerontology (2nd edition). Burlington, MA: Academic Press.

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Lints-Martindale, A. C., Hadjistavropoulos, T., Lix, L. M., & Thorpe, L. (2012). A comparative investigation of observational pain assessment tools for older adults with dementia. Clinical Journal of Pain, 28(3), 226-237. doi:10.1097/AJP.0b013e3182290d90

Lints-Martindale, A. C., Hadjistavropoulos, T., Lix, L. M., & Thorpe, L. (2012). A comparative investigation of observational pain assessment tools for older adults with dementia. Clinical Journal of Pain, 28(3), 226-237. doi:10.1097/AJP.0b013e3182290d90

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TREATMENT

Waters, S. J., Woodward, J. T., & Keefe, F. J. (2005). Cognitive-behavioural therapy for pain in older adults. In S. J. Gibson, & D. K. Weiner (Eds.), Pain in older persons (pp. 239-262). Seattle, WA: IASP Press.

Waters, S. J., Woodward, J. T., & Keefe, F. J. (2005). Cognitive-behavioural therapy for pain in older adults. In S. J. Gibson, & D. K. Weiner (Eds.), Pain in older persons (pp. 239-262). Seattle, WA: IASP Press.

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Morone, N. E., Lynch, C. S., Greco, C. M., Tindle, H. A., & Weiner, D. K. (2008). “I felt like a new person.” The effects of mindfulness meditation on older adults with chronic pain: Qualitative narrative analysis of diary entries. The Journal of Pain: Official Journal of the American Pain Society, 9(9), 841-848. doi:10.1016/j.jpain.2008.04.003

Morone, N. E., Lynch, C. S., Greco, C. M., Tindle, H. A., & Weiner, D. K. (2008). “I felt like a new person.” The effects of mindfulness meditation on older adults with chronic pain: Qualitative narrative analysis of diary entries. The Journal of Pain: Official Journal of the American Pain Society, 9(9), 841-848. doi:10.1016/j.jpain.2008.04.003

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Morone, N. E., Greco, C. M., & Weiner, D. K. (2008). Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study. Pain, 134(3), 310-319. doi:10.1016/j.pain.2007.04.038

Morone, N. E., Greco, C. M., & Weiner, D. K. (2008). Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study. Pain, 134(3), 310-319. doi:10.1016/j.pain.2007.04.038

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McCracken, L. M., & Jones, R. (2012). Treatment for chronic pain for adults in the seventh and eighth decades of life: A preliminary study of acceptance and commitment therapy (ACT). Pain Medicine, 13(7), 860-867. doi:10.1111/j.1526-4637.2012.01407.x

McCracken, L. M., & Jones, R. (2012). Treatment for chronic pain for adults in the seventh and eighth decades of life: A preliminary study of acceptance and commitment therapy (ACT). Pain Medicine, 13(7), 860-867. doi:10.1111/j.1526-4637.2012.01407.x

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Lunde, L., Nordhus, I. H., & Pallesen, S. (2009). The effectiveness of cognitive and behavioural treatment of chronic pain in the elderly: A quantitative review. Journal of Clinical Psychology in Medical Settings, 16(3), 254-262. doi:10.1007/s10880-009-9162-y

Lunde, L., Nordhus, I. H., & Pallesen, S. (2009). The effectiveness of cognitive and behavioural treatment of chronic pain in the elderly: A quantitative review. Journal of Clinical Psychology in Medical Settings, 16(3), 254-262. doi:10.1007/s10880-009-9162-y

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Green, S. M., Hadjistavropoulos, T., Hadjistavropoulos, H., Martin, R., & Sharpe, D. (2009). A controlled investigation of a cognitive behavioural pain management program for older adults. Behavioural and Cognitive Psychotherapy, 37(2), 221-226. doi:10.1017/S1352465809005177

Green, S. M., Hadjistavropoulos, T., Hadjistavropoulos, H., Martin, R., & Sharpe, D. (2009). A controlled investigation of a cognitive behavioural pain management program for older adults. Behavioural and Cognitive Psychotherapy, 37(2), 221-226. doi:10.1017/S1352465809005177

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Ferrell, B. R., Novy, D., Sullivan, M. D., Banja, J., Dubois, M. Y., Gitlin, M. C. . . . Livovich, J. (2001). Ethical dilemmas in pain management. Journal of Pain, 2(3), 171-180. doi: 10.1054/jpai.2001.21596

Ferrell, B. R., Novy, D., Sullivan, M. D., Banja, J., Dubois, M. Y., Gitlin, M. C. . . . Livovich, J. (2001). Ethical dilemmas in pain management. Journal of Pain, 2(3), 171-180. doi:  10.1054/jpai.2001.21596

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de Souto Barreto, P., Lapeyre-Mestre, M., Vellas, B., & Rolland, Y. (2013). Potential underuse of analgesics for recognized pain in nursing home residents with dementia: A cross-sectional study. PAIN, 154(11), 2427-2431.

de Souto Barreto, P., Lapeyre-Mestre, M., Vellas, B., & Rolland, Y. (2013). Potential underuse of analgesics for recognized pain in nursing home residents with dementia: A cross-sectional study. PAIN, 154(11), 2427-2431.

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Cleeland, C. S., Gonin, R., Hatfield, A. K., Edmonson, J. H., Blum, R. H., Stewart, J. A., & Pandya, K. J. (1994). Pain and its treatment in outpatients with metastatic cancer. New England Journal of Medicine, 330(9), 592-596. doi:10.1056/NEJM199403033300902

Cleeland, C. S., Gonin, R., Hatfield, A. K., Edmonson, J. H., Blum, R. H., Stewart, J. A., & Pandya, K. J. (1994). Pain and its treatment in outpatients with metastatic cancer. New England Journal of Medicine, 330(9), 592-596. doi:10.1056/NEJM199403033300902

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Ballard, C., Hanney, M. L., Theodoulou, M., Douglas, S., McShane, R., Kossakowski, K . . . Yu, L. (2009). The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow-up of a randomised placebo-controlled trial. The Lancet Neurology, 8(2), 151-157. doi: 0.1016/S1474-4422(08)70295-3

Ballard, C., Hanney, M. L., Theodoulou, M., Douglas, S., McShane, R., Kossakowski, K . . . Yu, L. (2009). The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow-up of a randomised placebo-controlled trial. The Lancet Neurology, 8(2), 151-157. doi: 0.1016/S1474-4422(08)70295-3

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