Navigating painful decisions: Pain management in older adults

Aging and pain The World Health Organization predicts that the number of individuals older than 60 years will increase from approximately 1 billion in 2019 to more than 2.1 billion by 2050.1 With this rapid expansion in the aging population, we can expect to see an increased impact of chronic conditions associated with advanced age. Chronic pain is one of these burdensome chronic conditions, with reports suggesting pain prevalence rates as high as 50%–75% in individuals 65 years of age or older.2,3,4 Causes of pain in this population can be variable and complex, with the most common being osteoarthritis, followed by neuropathic pain conditions (e.g., diabetic neuropathy, postherpetic neuralgia, poststroke pain).2 Pain in this burgeoning population is generally not well-controlled and evidence suggests that pain contributes negatively to cognitive outcomes, functional capacity and mobility.5,6 The burden of age on pain management The physiologic effects of aging are complex, making it challenging to simply apply pain management strategies used in younger populations. Complications such as dementia can make the diagnosis and evaluation of pain quite difficult.3,5,6,7 Other clinical considerations, such as higher rates of comorbid conditions and associated polypharmacy, as well as an increased susceptibility to adverse drug reactions (ADRs), add burden to therapeutic decision-making in this population.8,9,10 Furthermore, physiologic changes can have a profound impact on the pharmacokinetics of drugs used. Factors such as altered drug absorption and decreased clearance due to impaired renal or hepatic activity can significantly affect how drugs will behave with use.8,9,10 Behaviours can also complicate pain management in older adults. For example, activity avoidance due to fear of exacerbating pain often leads to outcomes, such as physical deconditioning, decreased socialization and depressed mood, which can ultimately worsen pain further.11 Best practices in the absence of evidence? Despite being one of the fastest growing age demographics, evidence for managing pain in the older population is sparse. In general, older adults are underrepresented in pain trials, which tend to have younger overall sample populations.12,13 When setting goals for pain management, focusing on function is one evidence-based strategy that is important in both younger and older adults.14,15 Complete removal of pain is almost never a viable target for chronic pain; therefore, it is important to establish goals that are meaningful to the patient, along with expectations that are realistic. Functional goals could include focusing on activities that add meaning and value to the individual’s life, such as being able to regularly visit a friend for coffee or take the family dog for a brief walk. Pharmacists are well-poised to discuss goal setting when dispensing new or repeat pain medications. These goals should be function-focused, using the SMART goal-setting strategy: Specific (clear and focused); Measurable (so you know when you reach the goal); Attainable/Action-oriented (actions are within the individual’s control); Realistic (high probability of success); and Time-based (set a deadline for the goal).14,15 When setting patient goals in your practice, be sure to document the discussion and follow up as appropriate to Getty Images reinforce and check on progress. Analgesics – Good to go, or more harm than good? The American Geriatrics Society and the Comprehensive Geriatric Assessment Toolkit have developed tools—BEERS16 and STOPP/START17 criteria, respectively—to assist with medication decision-making in older adults. Primary considerations that affect recommendations in pain management include individual comorbidities (e.g., hypertension, congestive heart failure); factors affecting drug metabolism and clearance (e.g., hepatic and renal dysfunction); polypharmacy and associated drug interactions; and increased incidence of ADRs and related harms.16,17 The BEERS and STOPP/ START drug therapy recommendations are comprehensive, with key points summarized in Table 1.16-22 Pharmacists—Easing the pain of pain medication In addition to goal setting, pharmacists can be involved in optimizing pain management in numerous ways. Pharmacotherapy must be carefully selected based on the individual’s current clinical picture, including comorbidities and polypharmacy, as well as susceptibility to ADRs; all of these should be verified by the pharmacist prior to dispensing (see Table 1). As well, pharmacists can ensure that dosing begins cautiously and is increased slowly, with frequent monitoring and check-ins. Importantly, pharmacists should conduct regular medication reviews to help to identify if a specific pain medication remains appropriate. Deprescribing can often have positive outcomes on various domains of pain, such as mood, energy and sleep quality.18 Deprescribing of other unnecessary agents, such as chronic benzodiazepines, can also lead to reductions in additive ADRs and reduce risks such as falls and cognitive decline.18 Summary Pharmacists can contribute significantly and meaningfully to the lives of older adults with chronic pain, helping to maintain the often volatile balance between improving quality of life and decreasing drug-related harms. The points summarized in Table 1 will provide a starting point to help pharmacists focus on specific key issues in managing chronic pain in older adults. Dana Turcotte, BSc(Pharm), PhD, is a clinical pharmacist at a multidisciplinary primary care clinic in Winnipeg, MB, and an Assistant Professor at the College of Pharmacy, University of Manitoba. Her practice focuses on safer opioid use and pain management. References World Health Organization. Ageing: overview. 2022. https://www.who.int/health-topics/ageing#tab=tab_1 (Accessed April 5, 2022). St. Sauver JL, Warner DO, Yawn BP, et al. Why patients visit their doctors: assessing the most prevalent conditions in a defined American population. Mayo Clinic Proceedings 2013;88(1):56-67. Patel KV, Guralnik JM, Dansie EJ, et al. Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study. Pain 2013;154:2649-57. Schopflocher D, Taenzer P, Jovey R. The prevalence of chronic pain in Canada. Pain Res Manag 2011;16:445-50. doi: 10.1155/2011/876306. Eggermont LHP, Leveille SG, Shi L, et al. Pain characteristics associated with the onset of disability in older adults: the maintenance of balance, independent living, intellect, and zest in the elderly Boston study. J Am Geriatr Soc 2014;62:1007-16. Jakobsson U, Hallberg IR, Westergren A. Overall and health related quality of life among the oldest old in pain. Quality of Life Research 2004;13:125-36. Simons W, Malabar R. J Adv Nurs 1995;22:663-9. Beyth RJ, Shorr RI. Epidemiology of adverse drug reactions in the elderly by drug class. Drugs Aging 1999;14:231-9. Bicket MC, Mao J. Chronic pain in older adults. Anesthesiol Clin 2015;33:577-90. Gagliese L, Melzack R. Chronic pain in elderly people. Pain 1997;70(1):3-14. Larsson C, Ekvall Hansson E, Sundquist K, et al. Impact of pain characteristics and fear-avoidance beliefs on physical activity levels among older adults with chronic pain: a population-based, longitudinal study. BMC Geriatr 2016;16:50. https:/doi.org/10.1186/s12877-016-0224-3. Mercadante S, Giarratano A. Assessing age and gender in studies of breakthrough pain medications. Curr Med Res Opin 2014;30:1353-6. 10.1185/03007995.2014.901942. Ali A, Arif AW, Bhan C, et al. Managing chronic pain in the elderly: an overview of the recent therapeutic advancements. Cureus 2018;10(9), e3293. https://doi.org/10.7759/cureus.3293. Adams N, Grieder D. Treatment planning for person-centered care. Amsterdam: Elsevier Academic Press; 2005. Nicolaidis C. Police officer, deal-maker, or health care provider? Moving to a patient-centered framework for chronic opioid management. Pain Medicine 2011;12:890-7. 2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019;67:674-94. https://doi.org/10.1111/jgs.15767. O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015;44:213-8. https://doi.org/10.1093/ageing/afu145. RxFiles. Pain management in older adults. RxFiles, 3rd ed. https://www.rxfiles.ca/rxfiles/uploads/documents/GeriRxFiles-Pain.pdf (Accessed April 1, 2022). Schmidt M, Lamberts M, Olsen A-MS, et al. Cardiovascular safety of non-aspirin non-steroidal anti-inflammatory drugs: review and position paper by the working group for Cardiovascular Pharmacotherapy of the European Society of Cardiology. Eur Heart J 2016;37:1015-23. Chou R, Huffman LH; American Pain Society; American College of Physicians. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 2007;147:505-14. doi: 10.7326/0003-4819-147-7-200710020-00008. Erratum in: Ann Intern Med 2008;148:247-8. Driot D, Jouanjus E, Oustric S, et al. Patterns of gabapentin and pregabalin use and misuse: results of a population-based cohort study in France. Br J Clin Pharmacol 2019; 85:1260-9. Velayudhan L, McGoohan K, Bhattacharyya S. Safety and tolerability of natural and synthetic cannabinoids in adults aged over 50 years: a systematic review and meta-analysis. PLoS Med 2021;18(3):e1003524.

Managing Pain

Navigating painful decisions: Pain management in older adults

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Dana Turcotte

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