A new holistic approach to pain management in older people
Nan Ma is specialist registrar in clinical Gerontology and Aza Abdulla is a consultant geriatrician and general physician at the Princess Royal University Hospital, Kings College NHS Foundation Trust. He is co-founder of the Special Interest Group on Pain in Older People in the British Geriatrics Society (BGS) and participated in producing the first National Guidelines on Management of Pain in Older People. He is also the immediate past president of the Geriatrics & Gerontology Section at the Royal Society of Medicine.
Pain in older people is under-reported and often poorly appreciated. For many, it is seen as part of normal ageing and has to be accepted. It is also a subjective feeling (different people have different pain thresholds) making it difficult for the clinician to quantify its impact in an individual patient. Consequently, it may be overlooked as an important factor that can affect older people’s wellbeing. In fact, chronic pain has a huge influence on quality of life (QoL) through its effects on the physical and mental state, which in turn adversely impacts on the older individual’s economic and social status (effects on carers, friends and family). Inadequately controlled pain perpetuates disability, anxiety, and depression all interfering with the overall QoL. It follows that effective management of pain is crucial in optimising welfare in the older person.
Two studies recently published in Age and Ageing aim to assess and characterise pain, and identify its impacts and associations with factors which may assist in the holistic approach to pain management. O’Sullivan et al and Kennedy et al undertook a longitudinal study among community dwellers over the age of 50 years in Ireland with the aim of generating a new pain profile which better characterises the severity and impact of pain on the individual. The questionnaire-based study recruited 8,171 participants. Baseline demographics including social, mental health, disability and quality of life indicators were assessed as well as specific questions regarding the sites, severity of pain, impact on life and polypharmacy. 35% of respondents reported being often troubled by pain. Cluster analysis of the data resulted in 4 pain profile generation, ranging from profile 1 where pain did not impact on life, to profile 4 which was multisite pain not controlled by medication and impacted on daily life. Patients in pain profile 3 and 4 had increased disability and more depression with a worse quality of life index compared to those with no pain or pain profile 1. Not unexpectedly, profile 3 and 4 also resulted in greater health utilisation. Compared to those with no pain, patients in profile 4 were two to three times more likely to have frequent GP attendance and hospital outpatient visits. The study concluded that the use of pain profiles, which take into account the impact of pain and its subjective nature, may enable better management and provide more accurate predictions of healthcare utilisation among older people. It is important to note however, due to the nature of the study the results are subject to reporter bias as well as selection bias. Perhaps more importantly, the study was not strictly limited to older people.
In the third paper, Kherad et al used a questionnaire based population study assessing the risk factors that may be associated with low back pain and sciatica in older men. The results suggest that the presence of low back pain is associated with a more negatively perceived health rating, reduced physical activity and increased feelings of depression. The authors concluded that these non- anatomical risk factors influence the subjective feeling of pain and in order to manage pain effectively these risk factors should also be considered and managed accordingly.
The results of these three studies may not be ground breaking but they certainly do highlight the importance of being more specific when asking about pain; questions like, does the pain make it difficult for you to pursue your usual daily activities, do you have many pain sites, are you taking medication for pain control, and how well is the pain control provide a more holistic picture of the impact of pain. These papers add further evidence to the available literature on the importance of pain management in older people both from the patient’s wellbeing and healthcare utilisation. For the clinician, they add impetus to the importance of appropriate pain management in older people.
The 2013 guidelines on the management of pain in the older person, published in Age and Ageing, gives a comprehensive overview of the management strategies which takes into account not only the pharmacology involved but also other interventions which should be considered and used as adjuncts. Given the impact pain has on the quality of life, not only physically but also mentally, management should be aimed at not only treating the symptom of pain with analgesia but also improving other risk factors such as mental wellbeing. Indeed, clinical depression affects many older people and the biopsychosocial model can influence greatly on how an individual perceives, experiences and copes with pain. Despite the close association of pain and depression, it is sometimes difficult to establish if pain leads to feelings of depression or whether pain is a somatisation of depression. What we do know is that studies have suggested that the use of antidepressants and cognitive behaviour therapy do have a role in management of pain and should be considered.
Pain management in the older person can be very difficult, not only as it is under reported but it often comes with many other factors which may be over looked. Recognition of these associated factors is vital in providing a management strategy which is holistic and targeted to the needs of the individual patient. Read the full Age & Ageing articles:
- Understanding pain among older persons: Part 1—the development of novel pain profiles and their association with disability and quality of life
- Understanding pain among older persons: Part 2—the association between pain profiles and healthcare utilisation