The link between pain and frailty revealed: it’s time to move towards more effective pain management in older people
Dr. Marcos Saraiva is a geriatrician from the Division of Geriatrics of University of São Paulo Medical School, Brazil. He and his co-authors recently published the paper Persistent pain is a risk factor for frailty: a systematic review and meta-analysis from prospective longitudinal studies in Age and Ageing journal.
Pain is a very common condition in older people, ranging from 40% in community-dwelling older adults to 80% in institutionalised individuals. It is known that pain, especially persistent pain (defined as a painful experience that continues for a prolonged period of time that may or may not be associated with a recognisable disease process), is associated with depression, social isolation, anxiety, insomnia, falls, higher health costs, weight loss, greater vulnerability to stressors and functional loss in older people.
On the other hand, frailty is a multidimensional geriatric syndrome, described as a spiral energy decline due to reduction in skeletal muscle mass (sarcopenia), neuroendocrine and immune dysfunctions. Frail older people have increased vulnerability to stressors and additional risk for important adverse events, such as hospitalisation, institutionalisation, falls, functional loss, and mortality.
Although the number of studies about pain in the older people is increasing, there are few studies that correlate pain with frailty. Both pain and frailty prevalence increase considerably with advancing age, and both are associated with functional decline and have a negative impact on the quality of life in this population.
In our study, a systematic review and meta-analysis using data from a large number of participants from longitudinal studies, we showed that persistent pain is a risk factor for frailty, since the presence of pain was associated with twice the risk of developing frailty over time. The presence of pain may contribute to and/or accelerate the process of frailty in older adults through the following mechanisms: reduction of mobility and physical activity, depression, social isolation and reduction of nutritional intake. These changes could leave older adults more vulnerable and less able to effectively adapt to physiologic stressors.
However, due to the presence of concomitant diseases, use of various medications, increased risk of adverse drug events, and challenges in pain evaluation (especially in patients with cognitive disfunction), pain treatment is still unfortunately low in the older population and almost 50% of them receive improper pain treatment. Moreover, still today it is often to hear, including from health professionals, the obsolete concept that pain is ‘expected as being part of normal aging’.
Thus, an adequate understanding of the mechanisms of pain in frail older adults is an important step in the development of target interventions for this population. Furthermore, the use of specific tools for assessing pain in older people (especially for those with dementia), education and training of health care professionals and multidimensional pain management strategies may be important for the prevention, slowing of progression, or even improvement of frailty, and it should be incorporated as a central element in frailty interventions.