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Sickle cell disease: Gaining control over the pain
Treating herpes zoster and postherpetic neuralgia: An evidence-based approach
Managing chronic pain in older adults: 6 steps to overcoming medication barriers
Dr. Reid is a consultant to sanofi aventis. Dr. Ayres and Mr. Warmington reported no potential conflict of interest relevant to this article.
Managing chronic pain in an older adult can be a complicated task, with risks for adverse effects, under- or overmedication, and nonadherence. Pain can be alleviated in many cases, however, if you address potential complications and barriers to effective treatment when prescribing analgesic medications.
Pain is a part of daily life for many older adults
As many as 50% of community-dwelling older adults experience a chronic pain disorder, defined as pain on most days for at least 3 consecutive months.1 Prevalence rates are typically higher (49%-84%) among residents of long-term care facilities.2 Untreated chronic pain can lead to health consequences such as depression, decreased ability to socialize, impaired ambulation, impaired sleep, increased falls, malnutrition, and decreased quality of life.1,3 Among older women, pain is the most common reported cause of impairment in activities of daily living.4
Arthritis and arthritis-related diseases (such as back pain) are common causes of chronic pain in older adults.5 Other causes include neuropathies, vertebral compression fractures, cancer and cancer treatments, and advanced chronic diseases such as end-stage heart, lung, and kidney disease.6-10
Substantial literature documents that chronic pain is underdetected and undertreated with advancing age11,12 and strongly supports efforts to improve pain care in later life. Treatment guidelines recommend a multimodal approach, including evidence-based nonpharmacologic treatments such as cognitive-behavioral therapy, exercise, and physical therapy.1 At the same time, pharmacotherapies remain the primary treatment used by physicians,13 and studies indicate that older people use analgesics frequently:
- When 551 older black and non-Hispanic white adults with osteoarthritis were interviewed, more than 80% of each group reported regular use of prescription and over-the-counter (OTC) analgesic medications.14
- In a cross-sectional study of 272 community-dwelling older adults with chronic pain from diverse causes, 59% reported routine use of an analgesic medication.15
The following 6 steps can improve the likelihood of a successful analgesic trial when managing chronic pain in people ages 65 and older. They take into account barriers you are likely to encounter, including polypharmacy, multimorbidity, cognitive and sensory impairment, sociodemographic factors, specific health beliefs about pain and pain treatments, and age-related physiologic changes.
TABLE
Refine your approach to chronic pain in older patients with these 6 steps
| 1. Conduct a comprehensive pain history | Assess pain location and intensity, and ask how pain limits activity. What treatments have been tried? What worked best? Any intolerable adverse effects? |
| 2. Review the problem list | Obtain a full medication list (OTC and supplements) to identify potential interactions. What chronic conditions (kidney or liver disease, movement disorders, neurologic problems) might worsen with analgesic medication or operate as a contraindication? Which drugs or comorbidities might affect treatment choices? |
| 3. Establish treatment goals | Address potential unrealistic expectations (eg, complete relief of pain or no benefit from treatment). The patient’s goals might differ from yours; come to a mutual decision about the most important outcomes. |
| 4. Identify barriers to therapy | Be aware of how cognitive or sensory impairment, sociodemographic factors, or health beliefs may limit medication adherence. Elicit the patient’s concerns about medications and discuss openly. Include the caregiver, as needed, when discussing treatments and monitoring outcomes. |
| 5. Start low and go slow when initiating analgesia | Avoid “start low and stay low,” which can contribute to undertreatment. If treatment goals are not met and the patient is tolerating therapy, advancing the dose is reasonable before trying another intervention. |
| 6. Assess for effects and outcomes | Make certain that the patient (or caregiver) understands what adverse effects might occur, and create a plan to address them. Establish how often and when communication should occur. Encourage telephone calls and/or e-mail to communicate questions or concerns. |
| OTC, over the counter | |
Step 1. Conduct a comprehensive pain history
The first step in pain management is to perform a comprehensive pain assessment. Without a proper pain assessment, it will be difficult to effectively treat and monitor response to treatment. Whichever pain scale you decide to use, it is important to use the same pain scale consistently each time a pain assessment takes place.3 The numeric rating scale and verbal descriptor scales (or pain thermometer) are widely used and have been shown to be preferred in the older adult population.3,16 The numeric rating scale asks a patient to rate his or her pain on a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain imaginable. The verbal descriptor scale is a measure of pain intensity on a vertical scale (typically a thermometer) from “no pain” to “excruciating.”3
Recommendations. In addition to assessing the intensity of the pain using a pain assessment tool, it is important to determine certain characteristics of the pain. What is the location and quality of the pain? Ask patients how the pain limits them. What prior treatments have been tried and failed? What has worked the best? What treatment/coping strategies are they using now? Have they had any intolerable adverse effects from specific treatments? Reliable predictors of treatment response require further definition,17 but a successful trial of a given analgesic in the past is often a good indicator of what might work again.
Step 2. Review the patient’s problem list
Use of multiple medications. Polypharmacy—with 5 or more being a typical threshold criterion—is common in people ages 65 and older and frequently complicates the pharmacologic management of chronic pain.16,18 Complications most often occur as a result of drug-drug interactions.
Multiple coexisting chronic conditions. Multimorbidity is common in older adults with chronic pain. Consider co-occurring diabetes, hypertension, and osteoporosis when initiating any trial of a pain medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in treating pain syndromes, but their use can be hazardous in older individuals, particularly those with coexisting hypertension, cardiovascular disease, history of peptic ulcer disease or gastropathy, or impaired renal function. NSAID use has been implicated as a cause of approximately one-quarter of all hospitalizations related to drug adverse effects among adults over age 65.1
NSAIDs can be effective in treating pain syndromes, but their use can be hazardous in older patients with hypertension, peptic ulcer disease, or impaired renal function.
The geriatric syndrome of frailty is defined by deficits in physiologic reserve and decreased resistance to multiple stressors.19 Risk of fracture is a particular concern of clinicians, older patients, and their caregivers. Opioids are the analgesic medications most often associated with increased fracture risk. In a recent analysis of Medicare claims data, opioid users were found to have a significantly increased fracture risk compared with users of nonselective NSAIDs.20 Mechanisms underlying this association include opioid-associated cognitive dysfunction and worsening gait/balance function.
Recommendations. Obtain a full list of the patient’s medications, including all OTC and complementary preparations. Also consider chronic kidney problems, liver disease, movement disorders, and neurologic problems when selecting a pharmacologic agent. Consider what chronic conditions might be made worse by an analgesic trial or would operate as a contraindication to starting a specific pain medication. Establish which medications or comorbidities might modify your treatment choices.
Step 3. Establish the patient’s treatment goals
We recommend shared decision-making when planning treatment and monitoring outcomes for older adults with chronic pain. Use your patient’s reports of the experience of pain— including pain intensity and how pain affects daily functioning1 —and identify his or her treatment goals, which might differ from yours. You may be aiming for the best pain relief possible, but your patient might be focused on practical issues such as increased mobility or ability to socialize. By talking openly, you can reach consensus and agree upon realistic treatment goals.
This approach can improve patients’ outcomes and satisfaction with treatment; it also has been shown to improve physician satisfaction when treating patients with chronic pain.21 In a recent qualitative study, older individuals varied in how much they wanted to participate in making decisions and being a “source of control” in their pain treatment. 22 Some patients—particularly those ages 80 and older—prefer to have their physicians make treatment decisions for them, whereas others embrace active participation. Regardless of how much older individuals wish to share in treatment decisions, they all value being listened to and understood by their physicians.21
Recommendations. The patient’s goals and expectations for treatment may or may not be the same as yours. Before starting a medication trial, address potential unrealistic expectations such as complete relief of pain or a belief that treatment is not likely to help. Come to a mutual decision as to what constitutes the most important outcomes, and you will then be able to monitor and assess treatment success.
Step 4. Identify barriers to initiating and adhering to therapy
Cognitive impairment is a strong risk factor for undertreatment of pain. It can lead to underreporting of pain by patients or difficulty for clinicians in assessing treatment response from those who are unable to communicate pain effectively. A study of nursing home residents found that only 56% of those with cognitive impairment received pain medications, compared with 80% of those with intact cognition.23 Older patients with cognitive deficits and memory loss also may take analgesic medications inappropriately or forget when/if they took them, increasing the risk of undertreatment or overdosing.
Fifty-six percent of nursing home residents with cognitive impairment received pain medications vs 80% of those with intact cognition.
Sensory impairment. Patients with visual deficits may have difficulty reading prescription bottle labels and information sheets. Those with auditory deficits may have trouble hearing, communicating, and understanding treatment instructions during a busy clinical encounter.
Sociodemographic factors. Many older adults live alone and have limited social support to encourage medication adherence.24 Some have significant caregiving responsibilities of their own (such as a spouse in poor health), which can lead to stress and inconsistent use of prescribed medications.25 Some older adults can’t afford the costs of certain pain medications and may take less than the prescribed amount.
Many older adults lack the necessary skills to read and process basic health care information, including understanding pill bottle instructions, information that appears in patient handouts, and clinicians’ instructions about possible adverse effects.26,27 Low health literacy can lead to problems with medication adherence (taking too much or too little of an analgesic medication) and associated complications.
Health beliefs. Many older adults believe chronic pain is a natural part of aging; in one study, this was true of 61% of approximately 700 primary care patients with osteoarthritis pain.28 Some older adults believe pain only gets worse over time,28 and others believe treatment for pain is not likely to provide any meaningful benefit.29,30 Beliefs such as these can lead to stoicism or acceptance of the status quo.31
Older adults also may endorse beliefs about pain medications that are likely to decrease their willingness to engage in, or adhere to, recommended pharmacologic interventions. Some use pain medicines sparingly because they fear addiction or dependence.32,33 Caregivers—often a spouse or adult child—also may express fears about the possibility of addiction.32 Finally, some older adults believe that using prescription analgesic medications invariably results in adverse effects;32 those who endorse this belief report minimizing medication use except when the pain is “very bad.”34
Recommendations. Elicit concerns patients may have about using analgesic medications and discuss them openly. Although not all barriers (such as economic issues) are modifiable, most (such as beliefs that pain medications are addictive) can be successfully addressed through patient education.
If other social support, such as a family member or caregiver in the home, could positively affect analgesic engagement/adherence, include these facilitators when discussing treatment decisions and in monitoring for medication effectiveness and adverse effects.
Step 5. Start low and go slow when initiating analgesia
Advancing age is associated with increased sensitivity to the anticholinergic effects of many commonly prescribed and OTC medications, including NSAIDs and opioids.35 Increasing the anticholinergic load can lead to cognitive impairments, including confusion, which can be particularly troublesome for older adults.1
Changes in pharmacokinetics (what the body does to the drug in terms of altering absorption, distribution, metabolism and excretion) and pharmacodynamics (what the drug does to the body in the form of adverse effects) occur as a function of advancing age. 1 Body fat increases by 20% to 40% on average, which increases the volume of distribution for fat-soluble medications.16 Hepatic and renal clearance decrease, leading to an increased half-life and decreased excretion of medications cleared by the liver or kidneys. Age-associated changes in gastrointestinal (GI) absorption and function include slower GI transit times and the possibility of increased opioid-related constipation from dysmotility problems.1
As a result of these physiologic changes, advancing age is associated with a greater incidence of drug-related adverse effects. Even so, individuals within the older population are highly heterogeneous, and no geriatric-specific dosing guidelines exist for prescribing pain medications to older adults.
Recommendations. We recommend the adage “start low and go slow” when initiating an analgesic trial for an older patient with chronic pain. This does not mean you should “start low and stay low,” which can contribute to undertreatment.36 If treatment goals are not being met and the patient is tolerating the therapy, advancing the dose is reasonable before moving on to another intervention.
We recommend that you “start low and go slow” but this does not mean that you should “start low and stay low.”
Step 6. Assess for effects and outcomes outside the office
Adverse effects are a primary reason older adults discontinue an analgesic trial.37 Make certain the patient (or caregiver, as appropriate) understands what adverse effects might occur, and create a plan to address them if they do.
Recommendations. Because many older people are reluctant to communicate with their physicians outside of an office visit, establish how often and when communication should occur. Telephone calls and/or e-mail are practical tools for patients to communicate questions or concerns to you, and you can enhance treatment outcomes with timely replies. In the near future, mobile health technologies may play a key role in monitoring for adverse effects and communicating positive treatment outcomes.
1. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57:1331-1346.
2. Won AB, Lapane KL, Vallow S, et al. Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. J Am Geriatr Soc. 2004;52:867-874.
3. Gagliese L, Melzack R. Chronic pain in elderly people. Pain. 1997;70:3-14.
4. Leveille SG, Fried L, Guralnik JM. Disabling symptoms: what do older women report? J Gen Intern Med. 2002;17:766-773.
5. Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum. 1998;41:778-799.
6. Schmader KE. Epidemiology and impact on quality of life of postherpetic neuralgia and painful diabetic neuropathy. Clin J Pain. 2002;18:350-354.
7. Rao A, Cohen HJ. Symptom management in the elderly cancer patient: fatigue, pain, and depression. J Natl Cancer Inst Monogr. 2004;32:150-157.
8. Potter J, Hami F, Bryan T, et al. Symptoms in 400 patients referred to palliative care services: prevalence and patterns. Palliat Med. 2003;17:310-314.
9. Walke LM, Byers AL, Tinetti ME, et al. Range and severity of symptoms over time among older adults with chronic obstructive pulmonary disease and heart failure. Arch Intern Med. 2007;167:2503-2508.
10. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31:58-69.
11. Landi F, Onder G, Cesari M, et al. Pain management in frail, community-living elderly patients. Arch Intern Med. 2001;161:2721-2724.
12. Institute of Medicine of the National Academies. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. June 29, 2011. Available at: http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx. Accessed June 27, 2012.
13. Sarzi-Puttini P, Cimmino MA, Scarpa R, et al. Do physicians treat symptomatic osteoarthritis patients properly? Results of the AMICA experience. Semin Arthritis Rheum. 2005;35(suppl 1):38-42.
14. Silverman M, Nutini J, Musa D, et al. Daily temporal self-care responses to osteoarthritis symptoms by older African Americans and whites. J Cross Cult Gerontol. 2008;23:319-337.
15. Barry LC, Gill TM, Kerns RD, et al. Identification of pain-reduction strategies used by community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60:1569-1575.
16. Fine PG. Treatment guidelines for the pharmacological management of pain in older persons. Pain Med. 2012;13(suppl 2):S57-S66.
17. Reid MC, Bennett DA, Chen WG, et al. Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them. Pain Med. 2011;12:1336-1357.
18. Slone Epidemiology Center at Boston University. Patterns of medication use in the United States 2006: a report from the Slone Survey. Available at: http://www.bu.edu/slone/SloneSurvey/AnnualRpt/SloneSurveyWebReport2006.pdf. Accessed June 27, 2012.
19. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146-M156.
20. Solomon DH, Rassen JA, Glynn RJ, et al. The comparative safety of analgesics in older adults with arthritis. Arch Intern Med. 2010;170:1968-1976.
21. Sullivan MD, Leigh J, Gaster B. Brief report: training internists in shared decision making about chronic opioid treatment for noncancer pain. J Gen Intern Med. 2006;21:360-362.
22. Teh CF, Karp JF, Kleinman A, et al. Older people’s experiences of patient-centered treatment for chronic pain: a qualitative study. Pain Med. 2009;10:521-530.
23. Reynolds KS, Hanson LC, DeVellis RF, et al. Disparities in pain management between cognitively intact and cognitively impaired nursing home residents. J Pain Symptom Manage. 2008;35:388-396.
24. Elliott RA. Poor adherence to medication in adults with rheumatoid arthritis: reasons and solutions. Dis Manage Health Outcomes. 2008;16:13-29.
25. Cardenas-Valladolid J, Martin-Madrazo C, Salinero-Fort MA, et al. Prevalence of adherence to treatment in homebound elderly people in primary health care: a descriptive cross-sectional, multicentre study. Drugs Aging. 2010;27:641-651.
26. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475-482.
27. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281:545-551.
28. Appelt CJ, Burant CJ, Siminoff LA, et al. Arthritis-specific health beliefs related to aging among older male patients with knee and/or hip osteoarthritis. J Gerontol A Biol Sci Med Sci. 2007;62:184-190.
29. Weiner DK, Rudy TE. Attitudinal barriers to effective treatment of persistent pain in nursing home residents. J Am Geriatr Soc. 2002;50:2035-2040.
30. Yates P, Dewar A, Fentiman B. Pain: the views of elderly people living in long-term residential care settings. J Adv Nurs. 1995;21:667-674.
31. Cornally N, McCarthy G. Chronic pain: the help-seeking behavior, attitudes, and beliefs of older adults living in the community. Pain Manage Nurs. 2011;12:206-217.
32. Spitz A, Moore AA, Papaleontiou M, et al. Primary care providers’ perspective on prescribing opioids to older adults with chronic non-cancer pain: a qualitative study. BMC Geriatrics. 2011;11:35.-
33. Chia LR, Schlenk EA, Dunbar-Jacob J. Effect of personal and cultural beliefs on medication adherence in the elderly. Drugs Aging. 2006;23:191-202.
34. Sale J, Gignac M, Hawker G. How “bad” does the pain have to be? A qualitative study examining adherence to pain medication in older adults with osteoarthritis. Arthritis Rheum. 2006;55:272-278.
35. Rudolph JL, Salow MJ, Angelini MC, et al. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168:508-513.
36. Hanlon JT, Backonja M, Weiner D, et al. Evolving pharmacological management of persistent pain in older persons. Pain Med. 2009;10:959-961.
37. Reid MC, Henderson CR, Jr, Papaleontiou M, et al. Characteristics of older adults receiving opioids in primary care: treatment duration and outcomes. Pain Med. 2010;11:1063-1071.
Sickle cell disease: Gaining control over the pain
Treating herpes zoster and postherpetic neuralgia: An evidence-based approach
Managing chronic pain in older adults: 6 steps to overcoming medication barriers
Dr. Reid is a consultant to sanofi aventis. Dr. Ayres and Mr. Warmington reported no potential conflict of interest relevant to this article.
Managing chronic pain in an older adult can be a complicated task, with risks for adverse effects, under- or overmedication, and nonadherence. Pain can be alleviated in many cases, however, if you address potential complications and barriers to effective treatment when prescribing analgesic medications.
Pain is a part of daily life for many older adults
As many as 50% of community-dwelling older adults experience a chronic pain disorder, defined as pain on most days for at least 3 consecutive months.1 Prevalence rates are typically higher (49%-84%) among residents of long-term care facilities.2 Untreated chronic pain can lead to health consequences such as depression, decreased ability to socialize, impaired ambulation, impaired sleep, increased falls, malnutrition, and decreased quality of life.1,3 Among older women, pain is the most common reported cause of impairment in activities of daily living.4
Arthritis and arthritis-related diseases (such as back pain) are common causes of chronic pain in older adults.5 Other causes include neuropathies, vertebral compression fractures, cancer and cancer treatments, and advanced chronic diseases such as end-stage heart, lung, and kidney disease.6-10
Substantial literature documents that chronic pain is underdetected and undertreated with advancing age11,12 and strongly supports efforts to improve pain care in later life. Treatment guidelines recommend a multimodal approach, including evidence-based nonpharmacologic treatments such as cognitive-behavioral therapy, exercise, and physical therapy.1 At the same time, pharmacotherapies remain the primary treatment used by physicians,13 and studies indicate that older people use analgesics frequently:
- When 551 older black and non-Hispanic white adults with osteoarthritis were interviewed, more than 80% of each group reported regular use of prescription and over-the-counter (OTC) analgesic medications.14
- In a cross-sectional study of 272 community-dwelling older adults with chronic pain from diverse causes, 59% reported routine use of an analgesic medication.15
The following 6 steps can improve the likelihood of a successful analgesic trial when managing chronic pain in people ages 65 and older. They take into account barriers you are likely to encounter, including polypharmacy, multimorbidity, cognitive and sensory impairment, sociodemographic factors, specific health beliefs about pain and pain treatments, and age-related physiologic changes.
TABLE
Refine your approach to chronic pain in older patients with these 6 steps
| 1. Conduct a comprehensive pain history | Assess pain location and intensity, and ask how pain limits activity. What treatments have been tried? What worked best? Any intolerable adverse effects? |
| 2. Review the problem list | Obtain a full medication list (OTC and supplements) to identify potential interactions. What chronic conditions (kidney or liver disease, movement disorders, neurologic problems) might worsen with analgesic medication or operate as a contraindication? Which drugs or comorbidities might affect treatment choices? |
| 3. Establish treatment goals | Address potential unrealistic expectations (eg, complete relief of pain or no benefit from treatment). The patient’s goals might differ from yours; come to a mutual decision about the most important outcomes. |
| 4. Identify barriers to therapy | Be aware of how cognitive or sensory impairment, sociodemographic factors, or health beliefs may limit medication adherence. Elicit the patient’s concerns about medications and discuss openly. Include the caregiver, as needed, when discussing treatments and monitoring outcomes. |
| 5. Start low and go slow when initiating analgesia | Avoid “start low and stay low,” which can contribute to undertreatment. If treatment goals are not met and the patient is tolerating therapy, advancing the dose is reasonable before trying another intervention. |
| 6. Assess for effects and outcomes | Make certain that the patient (or caregiver) understands what adverse effects might occur, and create a plan to address them. Establish how often and when communication should occur. Encourage telephone calls and/or e-mail to communicate questions or concerns. |
| OTC, over the counter | |
Step 1. Conduct a comprehensive pain history
The first step in pain management is to perform a comprehensive pain assessment. Without a proper pain assessment, it will be difficult to effectively treat and monitor response to treatment. Whichever pain scale you decide to use, it is important to use the same pain scale consistently each time a pain assessment takes place.3 The numeric rating scale and verbal descriptor scales (or pain thermometer) are widely used and have been shown to be preferred in the older adult population.3,16 The numeric rating scale asks a patient to rate his or her pain on a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain imaginable. The verbal descriptor scale is a measure of pain intensity on a vertical scale (typically a thermometer) from “no pain” to “excruciating.”3
Recommendations. In addition to assessing the intensity of the pain using a pain assessment tool, it is important to determine certain characteristics of the pain. What is the location and quality of the pain? Ask patients how the pain limits them. What prior treatments have been tried and failed? What has worked the best? What treatment/coping strategies are they using now? Have they had any intolerable adverse effects from specific treatments? Reliable predictors of treatment response require further definition,17 but a successful trial of a given analgesic in the past is often a good indicator of what might work again.
Step 2. Review the patient’s problem list
Use of multiple medications. Polypharmacy—with 5 or more being a typical threshold criterion—is common in people ages 65 and older and frequently complicates the pharmacologic management of chronic pain.16,18 Complications most often occur as a result of drug-drug interactions.
Multiple coexisting chronic conditions. Multimorbidity is common in older adults with chronic pain. Consider co-occurring diabetes, hypertension, and osteoporosis when initiating any trial of a pain medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in treating pain syndromes, but their use can be hazardous in older individuals, particularly those with coexisting hypertension, cardiovascular disease, history of peptic ulcer disease or gastropathy, or impaired renal function. NSAID use has been implicated as a cause of approximately one-quarter of all hospitalizations related to drug adverse effects among adults over age 65.1
NSAIDs can be effective in treating pain syndromes, but their use can be hazardous in older patients with hypertension, peptic ulcer disease, or impaired renal function.
The geriatric syndrome of frailty is defined by deficits in physiologic reserve and decreased resistance to multiple stressors.19 Risk of fracture is a particular concern of clinicians, older patients, and their caregivers. Opioids are the analgesic medications most often associated with increased fracture risk. In a recent analysis of Medicare claims data, opioid users were found to have a significantly increased fracture risk compared with users of nonselective NSAIDs.20 Mechanisms underlying this association include opioid-associated cognitive dysfunction and worsening gait/balance function.
Recommendations. Obtain a full list of the patient’s medications, including all OTC and complementary preparations. Also consider chronic kidney problems, liver disease, movement disorders, and neurologic problems when selecting a pharmacologic agent. Consider what chronic conditions might be made worse by an analgesic trial or would operate as a contraindication to starting a specific pain medication. Establish which medications or comorbidities might modify your treatment choices.
Step 3. Establish the patient’s treatment goals
We recommend shared decision-making when planning treatment and monitoring outcomes for older adults with chronic pain. Use your patient’s reports of the experience of pain— including pain intensity and how pain affects daily functioning1 —and identify his or her treatment goals, which might differ from yours. You may be aiming for the best pain relief possible, but your patient might be focused on practical issues such as increased mobility or ability to socialize. By talking openly, you can reach consensus and agree upon realistic treatment goals.
This approach can improve patients’ outcomes and satisfaction with treatment; it also has been shown to improve physician satisfaction when treating patients with chronic pain.21 In a recent qualitative study, older individuals varied in how much they wanted to participate in making decisions and being a “source of control” in their pain treatment. 22 Some patients—particularly those ages 80 and older—prefer to have their physicians make treatment decisions for them, whereas others embrace active participation. Regardless of how much older individuals wish to share in treatment decisions, they all value being listened to and understood by their physicians.21
Recommendations. The patient’s goals and expectations for treatment may or may not be the same as yours. Before starting a medication trial, address potential unrealistic expectations such as complete relief of pain or a belief that treatment is not likely to help. Come to a mutual decision as to what constitutes the most important outcomes, and you will then be able to monitor and assess treatment success.
Step 4. Identify barriers to initiating and adhering to therapy
Cognitive impairment is a strong risk factor for undertreatment of pain. It can lead to underreporting of pain by patients or difficulty for clinicians in assessing treatment response from those who are unable to communicate pain effectively. A study of nursing home residents found that only 56% of those with cognitive impairment received pain medications, compared with 80% of those with intact cognition.23 Older patients with cognitive deficits and memory loss also may take analgesic medications inappropriately or forget when/if they took them, increasing the risk of undertreatment or overdosing.
Fifty-six percent of nursing home residents with cognitive impairment received pain medications vs 80% of those with intact cognition.
Sensory impairment. Patients with visual deficits may have difficulty reading prescription bottle labels and information sheets. Those with auditory deficits may have trouble hearing, communicating, and understanding treatment instructions during a busy clinical encounter.
Sociodemographic factors. Many older adults live alone and have limited social support to encourage medication adherence.24 Some have significant caregiving responsibilities of their own (such as a spouse in poor health), which can lead to stress and inconsistent use of prescribed medications.25 Some older adults can’t afford the costs of certain pain medications and may take less than the prescribed amount.
Many older adults lack the necessary skills to read and process basic health care information, including understanding pill bottle instructions, information that appears in patient handouts, and clinicians’ instructions about possible adverse effects.26,27 Low health literacy can lead to problems with medication adherence (taking too much or too little of an analgesic medication) and associated complications.
Health beliefs. Many older adults believe chronic pain is a natural part of aging; in one study, this was true of 61% of approximately 700 primary care patients with osteoarthritis pain.28 Some older adults believe pain only gets worse over time,28 and others believe treatment for pain is not likely to provide any meaningful benefit.29,30 Beliefs such as these can lead to stoicism or acceptance of the status quo.31
Older adults also may endorse beliefs about pain medications that are likely to decrease their willingness to engage in, or adhere to, recommended pharmacologic interventions. Some use pain medicines sparingly because they fear addiction or dependence.32,33 Caregivers—often a spouse or adult child—also may express fears about the possibility of addiction.32 Finally, some older adults believe that using prescription analgesic medications invariably results in adverse effects;32 those who endorse this belief report minimizing medication use except when the pain is “very bad.”34
Recommendations. Elicit concerns patients may have about using analgesic medications and discuss them openly. Although not all barriers (such as economic issues) are modifiable, most (such as beliefs that pain medications are addictive) can be successfully addressed through patient education.
If other social support, such as a family member or caregiver in the home, could positively affect analgesic engagement/adherence, include these facilitators when discussing treatment decisions and in monitoring for medication effectiveness and adverse effects.
Step 5. Start low and go slow when initiating analgesia
Advancing age is associated with increased sensitivity to the anticholinergic effects of many commonly prescribed and OTC medications, including NSAIDs and opioids.35 Increasing the anticholinergic load can lead to cognitive impairments, including confusion, which can be particularly troublesome for older adults.1
Changes in pharmacokinetics (what the body does to the drug in terms of altering absorption, distribution, metabolism and excretion) and pharmacodynamics (what the drug does to the body in the form of adverse effects) occur as a function of advancing age. 1 Body fat increases by 20% to 40% on average, which increases the volume of distribution for fat-soluble medications.16 Hepatic and renal clearance decrease, leading to an increased half-life and decreased excretion of medications cleared by the liver or kidneys. Age-associated changes in gastrointestinal (GI) absorption and function include slower GI transit times and the possibility of increased opioid-related constipation from dysmotility problems.1
As a result of these physiologic changes, advancing age is associated with a greater incidence of drug-related adverse effects. Even so, individuals within the older population are highly heterogeneous, and no geriatric-specific dosing guidelines exist for prescribing pain medications to older adults.
Recommendations. We recommend the adage “start low and go slow” when initiating an analgesic trial for an older patient with chronic pain. This does not mean you should “start low and stay low,” which can contribute to undertreatment.36 If treatment goals are not being met and the patient is tolerating the therapy, advancing the dose is reasonable before moving on to another intervention.
We recommend that you “start low and go slow” but this does not mean that you should “start low and stay low.”
Step 6. Assess for effects and outcomes outside the office
Adverse effects are a primary reason older adults discontinue an analgesic trial.37 Make certain the patient (or caregiver, as appropriate) understands what adverse effects might occur, and create a plan to address them if they do.
Recommendations. Because many older people are reluctant to communicate with their physicians outside of an office visit, establish how often and when communication should occur. Telephone calls and/or e-mail are practical tools for patients to communicate questions or concerns to you, and you can enhance treatment outcomes with timely replies. In the near future, mobile health technologies may play a key role in monitoring for adverse effects and communicating positive treatment outcomes.
Sickle cell disease: Gaining control over the pain
Treating herpes zoster and postherpetic neuralgia: An evidence-based approach
Managing chronic pain in older adults: 6 steps to overcoming medication barriers
Dr. Reid is a consultant to sanofi aventis. Dr. Ayres and Mr. Warmington reported no potential conflict of interest relevant to this article.
Managing chronic pain in an older adult can be a complicated task, with risks for adverse effects, under- or overmedication, and nonadherence. Pain can be alleviated in many cases, however, if you address potential complications and barriers to effective treatment when prescribing analgesic medications.
Pain is a part of daily life for many older adults
As many as 50% of community-dwelling older adults experience a chronic pain disorder, defined as pain on most days for at least 3 consecutive months.1 Prevalence rates are typically higher (49%-84%) among residents of long-term care facilities.2 Untreated chronic pain can lead to health consequences such as depression, decreased ability to socialize, impaired ambulation, impaired sleep, increased falls, malnutrition, and decreased quality of life.1,3 Among older women, pain is the most common reported cause of impairment in activities of daily living.4
Arthritis and arthritis-related diseases (such as back pain) are common causes of chronic pain in older adults.5 Other causes include neuropathies, vertebral compression fractures, cancer and cancer treatments, and advanced chronic diseases such as end-stage heart, lung, and kidney disease.6-10
Substantial literature documents that chronic pain is underdetected and undertreated with advancing age11,12 and strongly supports efforts to improve pain care in later life. Treatment guidelines recommend a multimodal approach, including evidence-based nonpharmacologic treatments such as cognitive-behavioral therapy, exercise, and physical therapy.1 At the same time, pharmacotherapies remain the primary treatment used by physicians,13 and studies indicate that older people use analgesics frequently:
- When 551 older black and non-Hispanic white adults with osteoarthritis were interviewed, more than 80% of each group reported regular use of prescription and over-the-counter (OTC) analgesic medications.14
- In a cross-sectional study of 272 community-dwelling older adults with chronic pain from diverse causes, 59% reported routine use of an analgesic medication.15
The following 6 steps can improve the likelihood of a successful analgesic trial when managing chronic pain in people ages 65 and older. They take into account barriers you are likely to encounter, including polypharmacy, multimorbidity, cognitive and sensory impairment, sociodemographic factors, specific health beliefs about pain and pain treatments, and age-related physiologic changes.
TABLE
Refine your approach to chronic pain in older patients with these 6 steps
| 1. Conduct a comprehensive pain history | Assess pain location and intensity, and ask how pain limits activity. What treatments have been tried? What worked best? Any intolerable adverse effects? |
| 2. Review the problem list | Obtain a full medication list (OTC and supplements) to identify potential interactions. What chronic conditions (kidney or liver disease, movement disorders, neurologic problems) might worsen with analgesic medication or operate as a contraindication? Which drugs or comorbidities might affect treatment choices? |
| 3. Establish treatment goals | Address potential unrealistic expectations (eg, complete relief of pain or no benefit from treatment). The patient’s goals might differ from yours; come to a mutual decision about the most important outcomes. |
| 4. Identify barriers to therapy | Be aware of how cognitive or sensory impairment, sociodemographic factors, or health beliefs may limit medication adherence. Elicit the patient’s concerns about medications and discuss openly. Include the caregiver, as needed, when discussing treatments and monitoring outcomes. |
| 5. Start low and go slow when initiating analgesia | Avoid “start low and stay low,” which can contribute to undertreatment. If treatment goals are not met and the patient is tolerating therapy, advancing the dose is reasonable before trying another intervention. |
| 6. Assess for effects and outcomes | Make certain that the patient (or caregiver) understands what adverse effects might occur, and create a plan to address them. Establish how often and when communication should occur. Encourage telephone calls and/or e-mail to communicate questions or concerns. |
| OTC, over the counter | |
Step 1. Conduct a comprehensive pain history
The first step in pain management is to perform a comprehensive pain assessment. Without a proper pain assessment, it will be difficult to effectively treat and monitor response to treatment. Whichever pain scale you decide to use, it is important to use the same pain scale consistently each time a pain assessment takes place.3 The numeric rating scale and verbal descriptor scales (or pain thermometer) are widely used and have been shown to be preferred in the older adult population.3,16 The numeric rating scale asks a patient to rate his or her pain on a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain imaginable. The verbal descriptor scale is a measure of pain intensity on a vertical scale (typically a thermometer) from “no pain” to “excruciating.”3
Recommendations. In addition to assessing the intensity of the pain using a pain assessment tool, it is important to determine certain characteristics of the pain. What is the location and quality of the pain? Ask patients how the pain limits them. What prior treatments have been tried and failed? What has worked the best? What treatment/coping strategies are they using now? Have they had any intolerable adverse effects from specific treatments? Reliable predictors of treatment response require further definition,17 but a successful trial of a given analgesic in the past is often a good indicator of what might work again.
Step 2. Review the patient’s problem list
Use of multiple medications. Polypharmacy—with 5 or more being a typical threshold criterion—is common in people ages 65 and older and frequently complicates the pharmacologic management of chronic pain.16,18 Complications most often occur as a result of drug-drug interactions.
Multiple coexisting chronic conditions. Multimorbidity is common in older adults with chronic pain. Consider co-occurring diabetes, hypertension, and osteoporosis when initiating any trial of a pain medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in treating pain syndromes, but their use can be hazardous in older individuals, particularly those with coexisting hypertension, cardiovascular disease, history of peptic ulcer disease or gastropathy, or impaired renal function. NSAID use has been implicated as a cause of approximately one-quarter of all hospitalizations related to drug adverse effects among adults over age 65.1
NSAIDs can be effective in treating pain syndromes, but their use can be hazardous in older patients with hypertension, peptic ulcer disease, or impaired renal function.
The geriatric syndrome of frailty is defined by deficits in physiologic reserve and decreased resistance to multiple stressors.19 Risk of fracture is a particular concern of clinicians, older patients, and their caregivers. Opioids are the analgesic medications most often associated with increased fracture risk. In a recent analysis of Medicare claims data, opioid users were found to have a significantly increased fracture risk compared with users of nonselective NSAIDs.20 Mechanisms underlying this association include opioid-associated cognitive dysfunction and worsening gait/balance function.
Recommendations. Obtain a full list of the patient’s medications, including all OTC and complementary preparations. Also consider chronic kidney problems, liver disease, movement disorders, and neurologic problems when selecting a pharmacologic agent. Consider what chronic conditions might be made worse by an analgesic trial or would operate as a contraindication to starting a specific pain medication. Establish which medications or comorbidities might modify your treatment choices.
Step 3. Establish the patient’s treatment goals
We recommend shared decision-making when planning treatment and monitoring outcomes for older adults with chronic pain. Use your patient’s reports of the experience of pain— including pain intensity and how pain affects daily functioning1 —and identify his or her treatment goals, which might differ from yours. You may be aiming for the best pain relief possible, but your patient might be focused on practical issues such as increased mobility or ability to socialize. By talking openly, you can reach consensus and agree upon realistic treatment goals.
This approach can improve patients’ outcomes and satisfaction with treatment; it also has been shown to improve physician satisfaction when treating patients with chronic pain.21 In a recent qualitative study, older individuals varied in how much they wanted to participate in making decisions and being a “source of control” in their pain treatment. 22 Some patients—particularly those ages 80 and older—prefer to have their physicians make treatment decisions for them, whereas others embrace active participation. Regardless of how much older individuals wish to share in treatment decisions, they all value being listened to and understood by their physicians.21
Recommendations. The patient’s goals and expectations for treatment may or may not be the same as yours. Before starting a medication trial, address potential unrealistic expectations such as complete relief of pain or a belief that treatment is not likely to help. Come to a mutual decision as to what constitutes the most important outcomes, and you will then be able to monitor and assess treatment success.
Step 4. Identify barriers to initiating and adhering to therapy
Cognitive impairment is a strong risk factor for undertreatment of pain. It can lead to underreporting of pain by patients or difficulty for clinicians in assessing treatment response from those who are unable to communicate pain effectively. A study of nursing home residents found that only 56% of those with cognitive impairment received pain medications, compared with 80% of those with intact cognition.23 Older patients with cognitive deficits and memory loss also may take analgesic medications inappropriately or forget when/if they took them, increasing the risk of undertreatment or overdosing.
Fifty-six percent of nursing home residents with cognitive impairment received pain medications vs 80% of those with intact cognition.
Sensory impairment. Patients with visual deficits may have difficulty reading prescription bottle labels and information sheets. Those with auditory deficits may have trouble hearing, communicating, and understanding treatment instructions during a busy clinical encounter.
Sociodemographic factors. Many older adults live alone and have limited social support to encourage medication adherence.24 Some have significant caregiving responsibilities of their own (such as a spouse in poor health), which can lead to stress and inconsistent use of prescribed medications.25 Some older adults can’t afford the costs of certain pain medications and may take less than the prescribed amount.
Many older adults lack the necessary skills to read and process basic health care information, including understanding pill bottle instructions, information that appears in patient handouts, and clinicians’ instructions about possible adverse effects.26,27 Low health literacy can lead to problems with medication adherence (taking too much or too little of an analgesic medication) and associated complications.
Health beliefs. Many older adults believe chronic pain is a natural part of aging; in one study, this was true of 61% of approximately 700 primary care patients with osteoarthritis pain.28 Some older adults believe pain only gets worse over time,28 and others believe treatment for pain is not likely to provide any meaningful benefit.29,30 Beliefs such as these can lead to stoicism or acceptance of the status quo.31
Older adults also may endorse beliefs about pain medications that are likely to decrease their willingness to engage in, or adhere to, recommended pharmacologic interventions. Some use pain medicines sparingly because they fear addiction or dependence.32,33 Caregivers—often a spouse or adult child—also may express fears about the possibility of addiction.32 Finally, some older adults believe that using prescription analgesic medications invariably results in adverse effects;32 those who endorse this belief report minimizing medication use except when the pain is “very bad.”34
Recommendations. Elicit concerns patients may have about using analgesic medications and discuss them openly. Although not all barriers (such as economic issues) are modifiable, most (such as beliefs that pain medications are addictive) can be successfully addressed through patient education.
If other social support, such as a family member or caregiver in the home, could positively affect analgesic engagement/adherence, include these facilitators when discussing treatment decisions and in monitoring for medication effectiveness and adverse effects.
Step 5. Start low and go slow when initiating analgesia
Advancing age is associated with increased sensitivity to the anticholinergic effects of many commonly prescribed and OTC medications, including NSAIDs and opioids.35 Increasing the anticholinergic load can lead to cognitive impairments, including confusion, which can be particularly troublesome for older adults.1
Changes in pharmacokinetics (what the body does to the drug in terms of altering absorption, distribution, metabolism and excretion) and pharmacodynamics (what the drug does to the body in the form of adverse effects) occur as a function of advancing age. 1 Body fat increases by 20% to 40% on average, which increases the volume of distribution for fat-soluble medications.16 Hepatic and renal clearance decrease, leading to an increased half-life and decreased excretion of medications cleared by the liver or kidneys. Age-associated changes in gastrointestinal (GI) absorption and function include slower GI transit times and the possibility of increased opioid-related constipation from dysmotility problems.1
As a result of these physiologic changes, advancing age is associated with a greater incidence of drug-related adverse effects. Even so, individuals within the older population are highly heterogeneous, and no geriatric-specific dosing guidelines exist for prescribing pain medications to older adults.
Recommendations. We recommend the adage “start low and go slow” when initiating an analgesic trial for an older patient with chronic pain. This does not mean you should “start low and stay low,” which can contribute to undertreatment.36 If treatment goals are not being met and the patient is tolerating the therapy, advancing the dose is reasonable before moving on to another intervention.
We recommend that you “start low and go slow” but this does not mean that you should “start low and stay low.”
Step 6. Assess for effects and outcomes outside the office
Adverse effects are a primary reason older adults discontinue an analgesic trial.37 Make certain the patient (or caregiver, as appropriate) understands what adverse effects might occur, and create a plan to address them if they do.
Recommendations. Because many older people are reluctant to communicate with their physicians outside of an office visit, establish how often and when communication should occur. Telephone calls and/or e-mail are practical tools for patients to communicate questions or concerns to you, and you can enhance treatment outcomes with timely replies. In the near future, mobile health technologies may play a key role in monitoring for adverse effects and communicating positive treatment outcomes.
1. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57:1331-1346.
2. Won AB, Lapane KL, Vallow S, et al. Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. J Am Geriatr Soc. 2004;52:867-874.
3. Gagliese L, Melzack R. Chronic pain in elderly people. Pain. 1997;70:3-14.
4. Leveille SG, Fried L, Guralnik JM. Disabling symptoms: what do older women report? J Gen Intern Med. 2002;17:766-773.
5. Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum. 1998;41:778-799.
6. Schmader KE. Epidemiology and impact on quality of life of postherpetic neuralgia and painful diabetic neuropathy. Clin J Pain. 2002;18:350-354.
7. Rao A, Cohen HJ. Symptom management in the elderly cancer patient: fatigue, pain, and depression. J Natl Cancer Inst Monogr. 2004;32:150-157.
8. Potter J, Hami F, Bryan T, et al. Symptoms in 400 patients referred to palliative care services: prevalence and patterns. Palliat Med. 2003;17:310-314.
9. Walke LM, Byers AL, Tinetti ME, et al. Range and severity of symptoms over time among older adults with chronic obstructive pulmonary disease and heart failure. Arch Intern Med. 2007;167:2503-2508.
10. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31:58-69.
11. Landi F, Onder G, Cesari M, et al. Pain management in frail, community-living elderly patients. Arch Intern Med. 2001;161:2721-2724.
12. Institute of Medicine of the National Academies. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. June 29, 2011. Available at: http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx. Accessed June 27, 2012.
13. Sarzi-Puttini P, Cimmino MA, Scarpa R, et al. Do physicians treat symptomatic osteoarthritis patients properly? Results of the AMICA experience. Semin Arthritis Rheum. 2005;35(suppl 1):38-42.
14. Silverman M, Nutini J, Musa D, et al. Daily temporal self-care responses to osteoarthritis symptoms by older African Americans and whites. J Cross Cult Gerontol. 2008;23:319-337.
15. Barry LC, Gill TM, Kerns RD, et al. Identification of pain-reduction strategies used by community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60:1569-1575.
16. Fine PG. Treatment guidelines for the pharmacological management of pain in older persons. Pain Med. 2012;13(suppl 2):S57-S66.
17. Reid MC, Bennett DA, Chen WG, et al. Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them. Pain Med. 2011;12:1336-1357.
18. Slone Epidemiology Center at Boston University. Patterns of medication use in the United States 2006: a report from the Slone Survey. Available at: http://www.bu.edu/slone/SloneSurvey/AnnualRpt/SloneSurveyWebReport2006.pdf. Accessed June 27, 2012.
19. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146-M156.
20. Solomon DH, Rassen JA, Glynn RJ, et al. The comparative safety of analgesics in older adults with arthritis. Arch Intern Med. 2010;170:1968-1976.
21. Sullivan MD, Leigh J, Gaster B. Brief report: training internists in shared decision making about chronic opioid treatment for noncancer pain. J Gen Intern Med. 2006;21:360-362.
22. Teh CF, Karp JF, Kleinman A, et al. Older people’s experiences of patient-centered treatment for chronic pain: a qualitative study. Pain Med. 2009;10:521-530.
23. Reynolds KS, Hanson LC, DeVellis RF, et al. Disparities in pain management between cognitively intact and cognitively impaired nursing home residents. J Pain Symptom Manage. 2008;35:388-396.
24. Elliott RA. Poor adherence to medication in adults with rheumatoid arthritis: reasons and solutions. Dis Manage Health Outcomes. 2008;16:13-29.
25. Cardenas-Valladolid J, Martin-Madrazo C, Salinero-Fort MA, et al. Prevalence of adherence to treatment in homebound elderly people in primary health care: a descriptive cross-sectional, multicentre study. Drugs Aging. 2010;27:641-651.
26. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475-482.
27. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281:545-551.
28. Appelt CJ, Burant CJ, Siminoff LA, et al. Arthritis-specific health beliefs related to aging among older male patients with knee and/or hip osteoarthritis. J Gerontol A Biol Sci Med Sci. 2007;62:184-190.
29. Weiner DK, Rudy TE. Attitudinal barriers to effective treatment of persistent pain in nursing home residents. J Am Geriatr Soc. 2002;50:2035-2040.
30. Yates P, Dewar A, Fentiman B. Pain: the views of elderly people living in long-term residential care settings. J Adv Nurs. 1995;21:667-674.
31. Cornally N, McCarthy G. Chronic pain: the help-seeking behavior, attitudes, and beliefs of older adults living in the community. Pain Manage Nurs. 2011;12:206-217.
32. Spitz A, Moore AA, Papaleontiou M, et al. Primary care providers’ perspective on prescribing opioids to older adults with chronic non-cancer pain: a qualitative study. BMC Geriatrics. 2011;11:35.-
33. Chia LR, Schlenk EA, Dunbar-Jacob J. Effect of personal and cultural beliefs on medication adherence in the elderly. Drugs Aging. 2006;23:191-202.
34. Sale J, Gignac M, Hawker G. How “bad” does the pain have to be? A qualitative study examining adherence to pain medication in older adults with osteoarthritis. Arthritis Rheum. 2006;55:272-278.
35. Rudolph JL, Salow MJ, Angelini MC, et al. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168:508-513.
36. Hanlon JT, Backonja M, Weiner D, et al. Evolving pharmacological management of persistent pain in older persons. Pain Med. 2009;10:959-961.
37. Reid MC, Henderson CR, Jr, Papaleontiou M, et al. Characteristics of older adults receiving opioids in primary care: treatment duration and outcomes. Pain Med. 2010;11:1063-1071.
1. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57:1331-1346.
2. Won AB, Lapane KL, Vallow S, et al. Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. J Am Geriatr Soc. 2004;52:867-874.
3. Gagliese L, Melzack R. Chronic pain in elderly people. Pain. 1997;70:3-14.
4. Leveille SG, Fried L, Guralnik JM. Disabling symptoms: what do older women report? J Gen Intern Med. 2002;17:766-773.
5. Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum. 1998;41:778-799.
6. Schmader KE. Epidemiology and impact on quality of life of postherpetic neuralgia and painful diabetic neuropathy. Clin J Pain. 2002;18:350-354.
7. Rao A, Cohen HJ. Symptom management in the elderly cancer patient: fatigue, pain, and depression. J Natl Cancer Inst Monogr. 2004;32:150-157.
8. Potter J, Hami F, Bryan T, et al. Symptoms in 400 patients referred to palliative care services: prevalence and patterns. Palliat Med. 2003;17:310-314.
9. Walke LM, Byers AL, Tinetti ME, et al. Range and severity of symptoms over time among older adults with chronic obstructive pulmonary disease and heart failure. Arch Intern Med. 2007;167:2503-2508.
10. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31:58-69.
11. Landi F, Onder G, Cesari M, et al. Pain management in frail, community-living elderly patients. Arch Intern Med. 2001;161:2721-2724.
12. Institute of Medicine of the National Academies. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. June 29, 2011. Available at: http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx. Accessed June 27, 2012.
13. Sarzi-Puttini P, Cimmino MA, Scarpa R, et al. Do physicians treat symptomatic osteoarthritis patients properly? Results of the AMICA experience. Semin Arthritis Rheum. 2005;35(suppl 1):38-42.
14. Silverman M, Nutini J, Musa D, et al. Daily temporal self-care responses to osteoarthritis symptoms by older African Americans and whites. J Cross Cult Gerontol. 2008;23:319-337.
15. Barry LC, Gill TM, Kerns RD, et al. Identification of pain-reduction strategies used by community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60:1569-1575.
16. Fine PG. Treatment guidelines for the pharmacological management of pain in older persons. Pain Med. 2012;13(suppl 2):S57-S66.
17. Reid MC, Bennett DA, Chen WG, et al. Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them. Pain Med. 2011;12:1336-1357.
18. Slone Epidemiology Center at Boston University. Patterns of medication use in the United States 2006: a report from the Slone Survey. Available at: http://www.bu.edu/slone/SloneSurvey/AnnualRpt/SloneSurveyWebReport2006.pdf. Accessed June 27, 2012.
19. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146-M156.
20. Solomon DH, Rassen JA, Glynn RJ, et al. The comparative safety of analgesics in older adults with arthritis. Arch Intern Med. 2010;170:1968-1976.
21. Sullivan MD, Leigh J, Gaster B. Brief report: training internists in shared decision making about chronic opioid treatment for noncancer pain. J Gen Intern Med. 2006;21:360-362.
22. Teh CF, Karp JF, Kleinman A, et al. Older people’s experiences of patient-centered treatment for chronic pain: a qualitative study. Pain Med. 2009;10:521-530.
23. Reynolds KS, Hanson LC, DeVellis RF, et al. Disparities in pain management between cognitively intact and cognitively impaired nursing home residents. J Pain Symptom Manage. 2008;35:388-396.
24. Elliott RA. Poor adherence to medication in adults with rheumatoid arthritis: reasons and solutions. Dis Manage Health Outcomes. 2008;16:13-29.
25. Cardenas-Valladolid J, Martin-Madrazo C, Salinero-Fort MA, et al. Prevalence of adherence to treatment in homebound elderly people in primary health care: a descriptive cross-sectional, multicentre study. Drugs Aging. 2010;27:641-651.
26. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475-482.
27. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281:545-551.
28. Appelt CJ, Burant CJ, Siminoff LA, et al. Arthritis-specific health beliefs related to aging among older male patients with knee and/or hip osteoarthritis. J Gerontol A Biol Sci Med Sci. 2007;62:184-190.
29. Weiner DK, Rudy TE. Attitudinal barriers to effective treatment of persistent pain in nursing home residents. J Am Geriatr Soc. 2002;50:2035-2040.
30. Yates P, Dewar A, Fentiman B. Pain: the views of elderly people living in long-term residential care settings. J Adv Nurs. 1995;21:667-674.
31. Cornally N, McCarthy G. Chronic pain: the help-seeking behavior, attitudes, and beliefs of older adults living in the community. Pain Manage Nurs. 2011;12:206-217.
32. Spitz A, Moore AA, Papaleontiou M, et al. Primary care providers’ perspective on prescribing opioids to older adults with chronic non-cancer pain: a qualitative study. BMC Geriatrics. 2011;11:35.-
33. Chia LR, Schlenk EA, Dunbar-Jacob J. Effect of personal and cultural beliefs on medication adherence in the elderly. Drugs Aging. 2006;23:191-202.
34. Sale J, Gignac M, Hawker G. How “bad” does the pain have to be? A qualitative study examining adherence to pain medication in older adults with osteoarthritis. Arthritis Rheum. 2006;55:272-278.
35. Rudolph JL, Salow MJ, Angelini MC, et al. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168:508-513.
36. Hanlon JT, Backonja M, Weiner D, et al. Evolving pharmacological management of persistent pain in older persons. Pain Med. 2009;10:959-961.
37. Reid MC, Henderson CR, Jr, Papaleontiou M, et al. Characteristics of older adults receiving opioids in primary care: treatment duration and outcomes. Pain Med. 2010;11:1063-1071.