19 Chap Cotter

7/2/01

CHAPTER

4:02 PM

Page 333

19

Pain
Rosemary C. Polomano

The Epidemiology
of Pain Among Elders
Pain among elders is not a normal part of aging. In
most cases, chronic pain in the elderly is a symptom of pathological processes caused by disease or
other condition. Whatever the cause, pain experienced by elders is generally poorly controlled.
Liebeskind and Melzack contend that, pain is
most poorly managed in those most defenseless
against it the young and the old.1 Failure to
appreciate the alarming number of elders who suffer from pain is a major factor contributing to
ineffective pain management.
Until recently, knowledge about pain in elders
was limited, but research now documents variations in estimates of pain among elders according
to age groups, health status, level of independence,
and living situations. Although differences in reports of pain may be affected by definitions of
pain and willingness of subjects to report pain,2
some 7080% of elders experience pain at one
time or another.3 The incidence of pain in community-dwelling elders is about 2550% with higher
estimates, 4580%, reported for long-term-care
residents.4,5,6 Approximately 78% of the youngold (6069 years) have current complaints of pain,
and about 64% of the healthy oldest-old (8089
years and living independently) report some pain.7
Elsewhere, 45% of hospitalized elders (80 years
and older) complained of pain, with 19% experiencing moderate to severe pain.8 Those most at
risk are older adults with orthopedic problems
(hip and other fractures). Pain present during hospitalization is likely to persist after discharge, which
is significant for clinicians treating pain in home
health- and long-term-care settings.
Persistent pain is often attributed to chronic
musculoskeletal conditions, such as low-back pain,
rheumatoid and osteoarthritis, neurologic prob-

lems, and progressive cancer.9,10 Each of these painful conditions is associated with specific mechanisms for tissue injury. Thus, an understanding of
the pathophysiological processes of diseases and
conditions causing pain, and the effects on psychosocial outcomes, are important for clinicians.

Physiology of Pain
The anatomical and physiological origins of pain
provide the framework for assessing and treating
pain. Pain may result from thermal, mechanical,
and chemical activation of nociceptors, free nerve
endings located in various body tissues and structures. Pain stimuli originating in the peripheral
nerves are transmitted through specific fibers to
pathways in the spinal cord and terminate in the
thalamus. Sensory input from the thalamus is conveyed, in turn, to central areas of the brain where
these painful stimuli are processed and perceived.
Somatic pain arising from subcutaneous tissues of
the skin, muscles, bones, and other support structures, and visceral pain from linings of body cavities
and organs, result from activation of nociceptors.
Characteristics of these types of pain, underlying
pathophysiological mechanisms, and examples of
acute and chronic pain syndromes experienced by
elders are outlined in Table 191.
The most disturbing and complex pain, caused
by damage to nerve fibers in the periphery or
spinal cord and brain, is nerve injury or neuropathic pain. Distinctions between neuropathic
versus somatic or visceral pain lie not only in
mechanisms for the pain, but also in the responses
to treatment. Neuropathic pain is believed to occur
from direct damage to nerves, rather than from
activation of nociceptors. It is a complex pain syndrome arising from nerve injury anywhere in the
nervous system. Direct insults to nerves lead to
very puzzling manifestations, such as persistent

333

19 Chap Cotter

7/2/01

4:02 PM

Page 334

334

Part 3:

Functional and Clinical Problems Associated with Frailty

Table 191 Pathophysiological Mechanisms and Examples of Acute and Chronic Pain Syndromes
Experienced by Elders
Type of
Pain

Physiologic
Structures

Mechanism
of Pain

Somatic
pain

Cutaneous: skin
and subcutaneous tissues
Deep somatic:
bone, muscle,
blood vessels,
connective
tissues

Postoperative
Activation of Localization of
incisional pain
nociceptors
cutaneous pain:
Pain at the insertion
well localized
sites of tubes
Localization of
and drains
deep somatic pain:
Bone or hip fractures
less well defined
Skeletal muscle
Common
descriptions:
constant, achy

Visceral
pain

Organs and the

Activation of Localization: poorly
linings of body
nociceptors
localized, diffuse,
cavities
deep

Neuropathic Nerve fibers

Spinal cord
pain
Central nervous
system

Characteristics
of Pain

Examples of
Acute Pain

Chest and abdominal

tubes and drains
Bladder distention or
spasms
Intestinal distention
Common
Pericarditis
descriptions:
cramping, splitting Constipation

Localization: poorly
Nonlocalized
nociceptive
Injury to the
nervous
system
structures

Common
descriptions:
shooting, hotburning, fire-like,
electric shock-like,
sharp, painfully
numb

pain, even after an injury resolves, or pain disproportionate to the damage.11,12 Central neuropathic
pain can be due to a lesion or dysfunction in the
central nervous system or thalamic pain from extrathalamic lesions. A classic example of central pain
is post-stroke pain syndrome accompanying a cerebrovascular accident (CVA). Patients often report,
or indicate through behavior, pain on the affected
side of the body, although peripheral injury is not
evident. Phantom limb is another example of central pain.

Phantom limb pain

Post-mastectomy
pain
Nerve compression

Sources of
Chronic Pain
Bony metastases
Degenerative or
osteoarthritis
Rheumatoid arthritis
Compression fractures
from osteoporosis
Back pain
Peripheral vascular
disease
Chronic stasis ulcers
Organ metastases
Spastic bowel
Inflammatory
bowel disease
Hiatal hernia
Chronic hepatitis
Diabetic neuropathy
Herpes zoster-related
pain
Cancer-related
nerve injury
Chronic phantom
limb pain
Trigeminal neuralgia
Central post-stroke
pain
Post-mastectomy
syndrome

Typically, neuropathic pain is described as a very

distressing sensation, such as hot or burning, firelike, and constrictive. Paroxysmal firing, or ectopic
discharge of damaged neurons, produces pain characteristically described as shooting or electric
shock-like. Neuropathic pain is difficult to diagnose; however, sensory and sometimes motor
deficits can be detected in the area of nerve
damage. An understanding of the pathological
process, along with a pain history and clinical
exam, are essential for the diagnosis of neuropathic

19 Chap Cotter

7/2/01

Chapter 19:

4:02 PM

Page 335

335

Pain

pain syndromes. Radiological evaluations with

x-rays, computed tomography (CT) scans, and
magnetic resonance imaging (MRI), while not
conclusive for neuropathic pain, may demonstrate
abnormal findings in areas of major nerves and
nerve plexuses. Clinically, neuropathic pain is
associated with the following abnormalities:12
Alterations in sensory modalities such as
touch, pressure, and thermal sensations

Patient-related barriers are identified in the literature.1316 Therapeutic interventions, from pain
assessment practices to education and counseling,
must be directed toward these barriers:
Inability to express pain due to altered
cognitive function and mental status
(e.g., dementia, delirium)
Decreased perceptual acuity

Allodynia (pain evoked from stimuli that are

generally not painful, such as touch)

Fear of side effects from opioid analgesics

or other analgesic medication (e.g., sedation, constipation, cognitive disturbance)

Dysesthesia (an unpleasant abnormal sensation, whether spontaneous or evoked)

Concerns about addiction

Hyperalgesia (exaggerated pain to stimuli

that are normally painful)
Hyperpathia (a painful syndrome characterized by increased reaction to a stimulus,
especially a repetitive stimulus, as well as an
increased threshold)

Reluctance to report pain for fear that

complaints will not be taken seriously
Fear that worsened pain means worsening
of disease
Desire to be a good patient and not complain

Descriptions of the pain as lancinating, shooting, burning, fire-like, or painfully numb

Lack of understanding about the impact of

uncontrolled pain

Motor weakness in the affected area

Persuasion by family members to avoid

taking medication for pain

Barriers to Assessment
and Control of Pain in the Elderly
Several barriers are responsible for inadequate
assessment and undertreatment of pain among elders. Fortunately, many of these barriers have been
identified, and advance practice nurses (APNs)
are in a key position to work collaboratively with
patients and professionals to clarify misconceptions about pain and its management.
Patient-Specific Barriers
First and foremost, clinicians must provide a climate in which patients can report pain and obtain
relief. Elders have numerous misconceptions with
regard to pain and pain therapies, particularly
those with cancer-related pain. Misinformation
held by family members must also be addressed,
as family members often influence a patients reports of pain and compliance with treatment.

Health Professional Barriers

Health professionals caring for the elderly practice
with numerous myths and misconceptions. Unfortunately, attitudes and beliefs about pain and
analgesic therapies play a major role in limiting
the use of effective pain medications. Nursing home
residents, who experience the most pain, are often
deprived of analgesic medications, often because
they are unable to communicate pain, appear withdrawn, or the magnitude of pain is underestimated
by care providers. This happens especially for the
cognitively impaired, despite evidence that patients
with altered cognitive states can accurately communicate their pain.15,17 Self-reports of pain from
the cognitively impaired may be just as valid as
reports from those who are cognitively intact.18
This problem is not limited just to cognitively
impaired elders or those in long-term care facilities, but even in oncology outpatient settings as
well, where older persons with cancer receive sig-

19 Chap Cotter

336

7/2/01

4:02 PM

Page 336

Part 3:

nificantly less analgesic medications compared to

younger adults.19
Among nurses (and others), lack of knowledge is
a major challenge in the diagnosis and treatment of
pain.19,20,21 Unfounded concerns over tolerance,
physical dependence, and addiction stem from confusion regarding the definitions of these terms.
Tolerance is defined as resistance to the effects of
a drug, whereby increased doses are needed over
time to sustain the same effect. More often than
not, an increased need for opioid analgesics is usually explained by worsening pain and variability in
response to opioid analgesics. Although some tolerance to opioid analgesics occurs over time, this is
not generally a clinical problem.
Physical dependence occurs with continued use
of opioid analgesics, as opioid-agonists (morphinelike opioids) bind to the receptor. Over time,
receptors become accustomed to opioids and when
the opioid is abruptly withdrawn, activation of the
autonomic nervous system brings about physical
withdrawal. Patients with physical dependence can be
safely weaned from opioid therapy, should their pain
resolve or diminish. To prevent acute physiological
withdrawal, opioid doses can be reduced no more
than 10% each day. Tapering schedules should be
individualized, however, as some patients require
slower reductions in daily dosages.
Addiction is neither tolerance nor physical
dependence; rather, it is a behavioral and social
phenomenon rooted in drug abuse and craving.
No published data support the likelihood of addiction among elders treated for pain. Occasionally,
behaviors thought to be signs of addiction occur.
These may include frequent requests or watching
the clock for medication, preoccupation with pain,
and emotional outbursts. Such behaviors most
likely stem from opioids with insufficient analgesic
efficacy or ineffective doses of short-acting opioids
that are improperly administered.
Other barriers that contribute to the inadequate
treatment of pain by health professionals include:
Lack of appreciation for the magnitude of pain
Inability to appreciate individualized
responses to pain
Lack of knowledge about the physiology
of pain

Functional and Clinical Problems Associated with Frailty

Belief that pain is a normal part of aging

Belief that long-term pain is more tolerable
over time
Misconception that older people experience
less pain than younger people
Misinformation regarding the efficacy of
less-potent analgesics
Traditional and standardized approaches
to pain
Concerns over potential adverse effects from
opioid and other analgesics (e.g., sedation,
increased risk for self-injury such as falls)
Fear of investigations or repercussions
from drug enforcement agencies for prescribing opioids
Systems-Related Barriers
Health systems-related barriers impose significant
limitations on clinicians abilities to treat pain
in elders effectively, especially in long-term-care
facilities. Not only is pain poorly managed in
long-term-care residents; interventions to enhance
comfort care are hindered further by institutional
factors.5 Despite the selected, but growing and
effective, use of nurse and pharmacist consultants
from provider pharmacies, along with palliative
care and hospice services, residents in long-termcare facilities still suffer from unrelenting pain.
Stein and Ferrell provide a comprehensive review
of factors that influence pain practices in longterm care.5

Barriers Encountered in
Long-Term-Care Facilities
Limited education of professional and nonprofessional staff
Reluctance to refer patients to outside pain
clinics or centers
Limited drug formulary options for pharmacotherapy, especially for opioids
Standardized protocols for analgesic therapy
that encourage fixed doses and dosing intervals of analgesics without individualizing
medication regimens

19 Chap Cotter

7/2/01

Chapter 19:

4:02 PM

Page 337

337

Pain

Outdated policies and procedures for medication administration

Often presents with restlessness, apprehension, anxiety, or inability to concentrate

Limited staffing resources to assess pain

and implement flexible analgesic therapy
schedules

Generally subsides with or without

treatment

Misinterpretation of restrictions imposed on

practice by state regulations (e.g., the use of
psychoactive drugs)
Overcoming these barriers to pain control require familiarity with evidence-based literature,
ongoing education, and resocialization of clinicians concerning practices for pain management.
The latter is best accomplished through collaboration among physicians, nurses, pharmacists, and
other professionals, along with the nonprofessional staff and facility administrators. Evidenceand consensus-based guidelines published by
authoritative agencies and organizations such as
the American Geriatrics Society, Agency for Healthcare Research and Quality (AHRQ), and the
American Pain Society can be powerful sources for
changing practice.6,2224

Pain Assessment and Evaluation

Numerous factors complicate the pain assessment
process in the elderly. Validated age-specific pain
assessment criteria and measurements exist and
can be implemented in clinical practice; however,
reluctance to appreciate the incidence and magnitude of pain hampers consistent use.
Acute Versus Chronic Pain
Distinctions between acute and chronic pain follow.

Acute Pain
Always serves a biologic purpose
Associated with physiological and autonomic responses
( BP, HR, RR)
Dilated pupils
Perspiration
Typically well described and localized

Chronic Pain
Never serves a biological purpose
Rarely associated with physiological and
autonomic responses
Poorly localized and described
Rarely resolves on its own
Can be progressive and debilitating
Often associated with depression and
altered mood states

Pain History
The American Geriatrics Society recommends use
of a comprehensive pain assessment form when
taking a pain history.6 Figure 191 represents the
dimensions of pain that should be evaluated as
recommended by the American Geriatrics Society.6
A pain history not only is important to understanding the pain experience, but also provides the
necessary data for designing analgesic regimens
and guiding psychosocial interventions. A comprehensive pain assessment and evaluation includes
the following.

Pain Pattern

Assess whether pain is constant,

intermittent, or both. Is pain associated with certain activities, ingestion of food, a particular time
of day, or other factors? Is the pattern of pain predictable? Answers to these questions are especially
useful for designing analgesic regimens. For example, pain that is moderate to severe, and both constant and intermittent, may require a regularly
scheduled opioid analgesic and a short-acting supplemental or rescue analgesic available on a prn
basis. Intermittent pain may be predictable, occurring at certain times of the day or in response to
specific circumstances (e.g., getting out of bed in
the morning), and treated accordingly.

19 Chap Cotter

7/2/01

4:02 PM

Page 338

338

Part 3:

Functional and Clinical Problems Associated with Frailty

GERIATRIC PAIN ASSESSMENT

Date:
Patients Name
Problem List:

Medical Record Number

Medications:

Pain Description:
Pattern:
Duration:
Location:
Character:
Lancinating
Radiating

Constant

Burning
Shooting

Intermittent

Stinging
Tingling

Other Descriptors:

Pain Intensity:
0
1
2
None

4
5
6
Moderate

Worst Pain in Last 24 hours:

0
1
2
3
4
5
6
None
Moderate

9
10
Severe

9
10
Severe

Mood:
Depression Screening Score:
Gait and Balance Score:
Impaired Activities:
Exacerbating Factors:

Relieving Factors:

Sleep Quality:
Bowel Habits:

Other Assessments or Comments:

Most Likely Cause of Pain:

Plans:

Figure 191
Example of a medical record form that can be used to summarize pain assessment in older persons.5

Breakthrough pain occurs at particular times,

despite use of regularly scheduled or around-theclock opioid analgesia. When breakthrough pain
occurs at the duration end-point for long-acting
analgesics, the dose can be increased (e.g., con-

trolled-released morphine [MS Contin], oxycodone

[OxyContin], and hydromorphone [Pallidone] or
transdermal fentanyl system [Duragesic]). With
short-acting opioids, consider increasing the dose,
decreasing the dosing interval, or switching to a

19 Chap Cotter

7/2/01

4:03 PM

Page 342

342

Part 3:

decrease in the pain, or the peak action or

duration of an analgesic in order to determine effectiveness.
Worst pain intensity (WPI): Indicates the
highest level of pain when it is most severe.
Ask patients to identify factors associated
with increased levels of pain such as getting
out of bed, ambulating, or with activities at
different times of the day. WPI levels indicate the usefulness or effectiveness of rescue or supplemental analgesia.
Least pain intensity (LPI): It is helpful to
know at what times or under what circumstances pain levels are at their lowest.

Character and Quality of the Pain

Several
instruments using descriptive words have been validated with older adults. The Short-Form McGill
Questionnaire (Figure 194) allows patients to
report sensations and feelings and to rate pain
intensity.29 The first 11 words define the sensory
component of pain and the last 4 capture its affective components. Aggressive attempts to manage
the pain and evaluate the presence of psychological
distress are critical for those patients who choose
words indicative of moderate to severe pain. In
these cases, ongoing efforts to manage both the pain
and the psychological distress are warranted.
Those with neuropathic pain tend to select
words like shooting, hot-burning, and stabbing.
Word choices can be monitored with the initiation
of adjuvant drug therapy, along with associated
features of neuropathic pain such as painful numbness, vasomotor responses, and motor weakness.

Perception of Pain Relief

A pain relief scale

is useful to determine perceptions of effectiveness
of the analgesic medication(s), especially with analgesics having no or limited documented use for
moderate to severe chronic pain (acetaminophen,
propoxyphene, and codeine). Various scales for
measuring pain relief are outlined in the AHRQ
clinical practice guidelines for cancer pain.23 Percentage rating scales, as in the Brief Pain Inventory,28 might be confusing to elders because the
numeric ratings are the opposite of those for pain
intensity. Higher values on pain relief indicate a

Functional and Clinical Problems Associated with Frailty

more favorable response, whereas higher values

for pain intensity indicate greater pain. It is very
easy and practical to simply ask patients if their
pain relief is acceptable.

Pain Expressions and Behaviors Behavioral

cues may be a significant indicator of pain, especially among elders with dementia or delirium.
Observe for grunting, groaning, facial grimacing,
wrinkled forehead, body positioning and movements (fetal position, guarding or holding a part
of the body, rubbing or massaging parts of the
body, etc.), reluctance to move or change position,
and ritualistic behaviors (rocking or pacing). Patients with neuropathic pain may experience cutaneous hypersensitivity to touch, pressure, heat, and
cold. Some simply experience pain from the contact of clothing on sensitive areas of the body.
Pain Diaries or Pain Flow Sheets Pain inventories or pain diaries enable clinicians to track patterns
of the pain, as well as allow patients an avenue for
self-expression concerning pain. A diary (depending
on whether maintained by the patient or for more
specific clinical purposes) should include date/time,
pain intensity (if possible), vital signs (if acute pain),
time-dependent analgesic administration, observations during ADLs, behaviors, general description,
pertinent assessment data, and any other relevant
information about the pain experience.
Pain in the Cognitively Impaired Elder
Assessing pain in cognitively impaired persons is
clinically challenging. Does pain or its treatment
exacerbate cognitive impairment? The coexistence
of pain with depression and dementia makes
assessment particularly difficult. Nevertheless,
almost all elders with degrees of cognitive impairment or even dementia have some capacity for
communicating pain, be it through facial expressions, unwillingness to move about, or other
behaviors. In a random sample of 217 elderly subjects (average age 85 years) in 10 nursing home
facilities, with varying degrees of cognitive impairment (Folstein Mini-Mental State Exam mean
score of 12.1 7.9), Ferrell and colleagues found

19 Chap Cotter

7/2/01

Chapter 19:

4:03 PM

Page 343

343

Pain

NONE

MILD

MODERATE

SEVERE

THROBBING

0)

1)

2)

3)

SHOOTING

0)

1)

2)

3)

STABBING

0)

1)

2)

3)

SHARP

0)

1)

2)

3)

CRAMPING

0)

1)

2)

3)

GNAWING

0)

1)

2)

3)

HOT-BURNING

0)

1)

2)

3)

ACHING

0)

1)

2)

3)

HEAVY

0)

1)

2)

3)

TENDER

0)

1)

2)

3)

SPLITTING

0)

1)

2)

3)

TIRING/EXHAUSTING

0)

1)

2)

3)

SICKENING

0)

1)

2)

3)

FEARFUL

0)

1)

2)

3)

PUNISHING/CRUEL

0)

1)

2)

3)

Figure 194
The Short-Form McGill Pain Questionnaire allows patients to rate pain
intensity.29

that most (83%) were able to use at least one of

five pain intensity scales, while 32% rated pain on
all five.15 The McGill Present Pain Intensity
Questionnaire had the highest completion rate.
When it is not possible to elicit subjective measurements of pain, ADLs, behaviors, and other

nonverbal cues should be observed. Data suggest

that independent activity or elective activities
such as ambulating, walking to the bathroom, rising from a sitting to standing position, and putting
on clothes may be more valid predictors of pain
than other self-report measures.15,30

19 Chap Cotter

7/2/01

4:03 PM

Page 344

344

Part 3:

Useful Strategies to Assess Pain in the

Cognitively Impaired Elder
Evaluate all possible physiological sources
for pain associated with diseases and painful
conditions.
Determine the presence of pain prior to
cognitive dysfunction.
Obtain histories from family members,
if possible.
Observe the patient during ADLs.
Observe nonverbal cues and behaviors.
Assess pain with aids that are designed for the
cognitively impaired (e.g., Faces Rating Scale).
Consistently use the same pain scale, by the
same health-care provider, where possible.
Assess responses to a trial of analgesic
medication.

Pain Management Therapies

Analgesic Therapy
When designing analgesic regimens for the treatment of either acute or chronic pain, it is important
to consider the following factors:
1. Etiology (disease-related, condition-related,
unclear, or unknown)
2. Physiological sources (somatic, visceral,
neuropathic, or any combination)
3. Mechanism (e.g., inflammation, muscle
spasm, visceral distention, nerve compression,
or infiltration)
4. Trajectory (progressive or nonprogressive)
5. Severity (mild, moderate, or severe)
6. Degree of physical debilitation
7. Duration
8. Confounding psychological variables (depression and anxiety)
9. Cognitive or mental status
10. Physiological changes from aging
Table 192 highlights those physiological changes
that occur with aging that are most likely to influence
the pharmacodynamics of analgesic therapy.3137

Functional and Clinical Problems Associated with Frailty

Management of Acute Pain

Postoperative Pain

Inadequate relief of postsurgical pain is linked to negative postoperative

outcomes.22 Misconceptions about the use of conventional methods for pain control are responsible
for their limited use for older persons. In general,
the same modalities used for adults are also effective with elders. Numerous studies have shown
that patient-controlled epidural analgesia and systemic patient-controlled analgesia offer the best
outcomes for pain and recovery compared to more
traditional prn nurse-administered analgesia.22 Unfortunately, technology-supported pain care is
underutilized for pain control in the elderly.
Severe postoperative pain has been associated with
altered mental status. There appears to be a strong
relationship between higher levels of pain at rest and
delirium in the first three days following noncardiac
surgery.38 Consistent pain relief is critically important following surgery. Adequate management of
postsurgical pain in the elderly leads to improvements in physiological variables such as neuroendocrine stress responses and pulmonary function.39
Combinations of aggressive pain techniques that
include regional analgesia tend to be most effective.
Although patientcontrolled analgesia (PCA) is an effective and safe
method for pain control in the elderly,40 the design
of PCA regimens are debated. Because elders are
more likely to experience a higher analgesic peak
and a longer duration from opioid analgesics, careful attention to PCA self-administered demand
doses and continuous or basal rate background
infusions are critical.
Morphine remains the opioid of choice for
PCA in both young and old. Compared to meperidine (Demerol), morphine is superior in relieving
pain, despite potential side effects of nausea, mood
disturbances, and unusual dreams.41 Meperidine
should be avoided in the elderly as it has an active
metabolite, normeperidine, that accumulates with
repeated doses. Toxic metabolites can also accumulate with morphine. Starting doses of morphine sulfate should be 0.5 to 1 mg per hour, with a demand
or self-administered dose of 1 mg at an interval of

Patient-Controlled Analgesia

Routinely evaluate liver and renal function

studies with long-term use of acetaminophen and NSAIDs.
Assess radiological evaluations of skeletal
structure (skeletal films, bone density
studies).
Promote independence with ADLs.
Encourage exercise and physical therapy
programs.
Institute treatment with methods of
cutaneous stimulation.
(continues)
Begin with nonopioid agents.
Do not exceed daily recommended doses
of > than 4,000 mg.
Use NSAIDs appropriately for inflammatory pain. Discontinue therapy if
analgesia is not effective.
Consider opioids for moderate to severe
pain from long-term effects of rheumatoid and osteoarthritis.
Prescribe and administer effective supplemental analgesia for provoked pain
associated with activity.

Degenerative joint disease

Joint stiffness
Decreased mobility

Musculoskeletal

7/2/01
4:03 PM

Osteoarthritis
Rheumatoid
arthritis
Back pain
Osteoporosis
with or without
compression
fractures
Bony metastases

Instruct patients to report changes in

vision.
Use pain assessment measures and teaching
materials that are easy to read.
Modify the environment (e.g., proper lighting, reduce noise and external stimuli).
Speak clearly and maintain eye contact.
Use medication labels that can be read
easily.
Ensure proper functioning of hearing aids.
Assess adherence to medication schedules.
Request feedback to ensure patients understand medication schedules.

Avoid drugs that are contraindicated

with glaucoma (e.g., agents with
anticholinergic effects)

Glaucoma
Cataracts

Decreased visual acuity

Increased drying of the
eyes
Hearing impairment

Hearing and
Visual Acuity

Perform baseline cognitive assessments and

monitor for changes in mental status.
Institute safety precautions.
Use appropriate age-specific pain measures
for the elderly and cognitively
impaired.
Use aids to facilitate memory deficits.
Allow ample response times for patients
who are slow to process information.

Assessment and Interventions

Use caution with psychoactive agents.

Select opioid agents with low side-effect
profile for sedation (e.g., hydrocodone,
oxycodone, and hydromorphone),
as well as adjuvant agents (e.g.,
gabapentin and desipramine).
Initiate therapy with one-half the usual
starting doses for adults.
Therapy with an SRI may be indicated
if depression persists following
adequate control of pain.

Preexisting Diseases
and Conditions
Considerations with Pharmacotherapy
Dementia
Alzheimers disease
Delirium
Depression

Physiological
Age-Related Changes

Age and Its Effects on Managing Pain6,3137

Mental Status Normal changes

Decreased mental acuity
Increased response
to sedating agents
Abnormal changes
Short-term memory
deficits
Slower processing
of information and
response

Table 192

19 Chap Cotter
Page 345

345

346
(continued)

Congestive heart
Reduced blood volume
failure
Decreased cardiac output
Hypertension
and reserve
Cardiac
Decreased circulation
arrhythmias
Conduction abnormalities

Gastropathy or
Changes in salivary flow
gastroparesis
and dentition
Constipation
Decreased fluid intake
Dehydration
Decreased gastric emptying

Cardiovascular

Gastrointestinal

COPD
Emphysema

Assessment and Intervention

For opioid and adjuvant therapy with

tricyclic antidepressants:
Maintain adequate fluid intake
Encourage good oral hygiene practices
Institute aggressive bowel regimens

Observe for increased signs and symptoms

of adverse effects from analgesics.
Assess for peripheral edema and signs
of worsening congestive heart failure.
Be aware of drug interactions (e.g., quinidine and tricyclic antidepressants).
Monitor digoxin levels and watch for signs
of digitoxicity for patients taking
NSAIDs.
ECG should be done before initiating
therapy with tricyclic antidepressants.
Assess patients for dizziness or syncope.

4:03 PM

Drug absorption, distribution, and

excretion may be altered by cardiovascular changes associated with aging.
Administer NSAIDs cautiously to
patients with congestive heart failure
due to a reduction in prostaglandins that
are necessary to maintain renal perfusion.
This increases the risk for fluid retention
and peripheral edema.
Reduction in renal function from NSAIDs
may interfere with elimination of digoxin, increasing the risk for digitoxicity.
Avoid tricyclic antidepressants if patients
have cardiac conduction defects.
Avoid NSAIDs in patients with a history
of peptic ulcer disease.
Avoid NSAIDs in patients concurrently
taking anticoagulants (e.g., warfarin).
Use opioids cautiously in patients who
are dehydrated, as they may be more
susceptible to opioid-related side effects.

Obtain baseline assessments of respirUse caution with opioid and other analtory status, especially for patients who
gesic agents that cause sedation.
are opioid-nave or debilitated, and
For patients who are opioid-nave, initiate
closely monitor respiratory rates.
opioid therapy using one-half the usual
Observe for early signs of respiratory
starting dose for adults.
insufficiency such as confusion or
Remember that the risk of respiratory
changes in breathing patterns.
depression from opioids is minimized
Encourage activity, and for patients who
if doses are escalated safely.
are bedridden, cough, turn, and deep
Respiratory depression from opioids is rarely
breathing exercises.
a problem for patients who are opioiddependent and tolerant to their effects.

Preexisting Diseases
and Conditions
Considerations with Pharmacotherapy

Decreased pulmonary
reserves

Physiological
Age-Related Changes

Age and Its Effects on Managing Pain6,3137

7/2/01

Pulmonary

Table 192

19 Chap Cotter
Page 346

Decrease renal filtration

and renal clearance

Renal

Obtain baseline BUN, creatinine, and creatinine clearance prior to initiating

therapy with NSAIDs, and monitor renal
function closely for long-term NSAID use.
Monitor digoxin levels and watch for signs
of digitoxicity if patients are taking
NSAIDs.
Monitor for adverse effects as a result
of prolonged drug clearance.
Monitor urinary output if patients are
receiving postoperative systemic opioids
or epidural analgesia.
Instruct patients taking opioids or tricyclic
antidepressants to report changes in
urination, and be aware of signs of
urinary tract infections.

Consider doses of 400 mg of ibuprofen

tid to reduce the risk of renal toxicity
with long-term use.
Avoid agents with toxic active metabolites that are excreted by the kidney
(meperidine, proproxyphene).
Patients who are opioid-nave are most
at risk for urinary retention.
Use caution with anticholinergic agents
(e.g., amitriptyline) that may cause
urinary retention.

Administer lower doses of opioid analgesics with longer intervals between

dosing.
Monitor liver function tests.

4:03 PM

Benign prostatic
hypertrophy in
men
Urinary incontinence, stress
incontinence in
women

Renal insufficiency

Avoid long-acting agents in patients with

hepatic dysfunction.
Use caution with opioids and adjuvant
agents with long T12.

7/2/01

Urinary

Delayed hepatic metabolism of drugs

Hepatic

19 Chap Cotter
Page 347

347

19 Chap Cotter

348

7/2/01

4:03 PM

Page 348

Part 3:

1015 minutes. For the oldest-old, 80 years or

older, intermittent demand dosing alone is recommended until response to therapy can be evaluated.
Elders require intensive teaching on the use of
PCA, preferably prior to surgery. In general, elders
are reluctant to access demand doses because of
fearfulness about medication effects or addiction.
Concerns about opioid analgesics should be addressed both pre- and postoperatively.
Regional Analgesia Epidural analgesia with either
opioid or local anesthetics, or a combination of
both, should be considered whenever possible.
Epidural analgesia is associated with improved
perfusion and pulmonary function, early mobilization, faster recovery of gastrointestinal function, reduced risk of thromboemboli, and lower
incidence of chronic pain following surgery (e.g.,
postamputation phantom limb pain).42 Elders
may be at risk for respiratory depression, especially
with epidural morphine. Fentanyl (Sublimaze) may
be a better choice for the elderly as it is less likely
to reach the central nervous system by rostral
(vertical) spread. Local anesthetics, such as bupivacaine (Marcaine), have an effect on sensory and
motor neurons and may cause orthostatic hypotension and lower motor weakness. Ropivacaine, selective for sensory nerves, may avoid motor effects.43
Epidural local anesthetics can decrease the sensation of pressure, especially in the skin. Long-acting
local anesthetics, for example, lidocaine, often
given as a bolus epidural injection, can produce
cognitive impairment if serum levels become toxic.
Use of epidural analgesia with elders requires
attention to the following points:

Use with caution for men with preexisting

bladder problems and benign prostatic
hypertrophy because of greater risk for urinary retention.
Administer lower concentrations of bupivacaine (Marcaine) (e.g., 0.050.0625% solutions) to minimize orthostatic hypotension
and lower motor weakness.
Note that elders who suffer from respiratory
disorders may be at increased risk for respiratory depression.

Functional and Clinical Problems Associated with Frailty

Assess cognitive status, which may be further compromised.

Monitor respiratory rates for the first 24
hours of therapy.
Assist patients while getting out of bed and
ambulating.
Reposition patients frequently while in bed.
Assess urinary function.
Management of Chronic Pain
Despite the high prevalence of pain among elders,
studies continue to document that older people
receive fewer analgesics.9,15,17 Guidelines on the
management of pain in older persons from the
American Geriatrics Society reflect the existing
research on pain and present evidence- and consensus-based recommendations on effective pharmacological and nonpharmacological interventions.6
There is no doubt that the management of cancer
pain in elders is fraught with fear of overmedicating patients and lack of knowledge as to the
appropriate use of analgesics. Specialized palliative care for elders has become a growing area of
specialization. Abrahm examines the components
of an effective pain program that includes decision-making criteria and strategies to reduce pain
and manage adverse effects from analgesics at the
end of life.44 While concerns remain about analgesic use, especially opioids in the elderly, problems
can be avoided with careful attention to initial
dosing, timing of doses, side effect profiles, agespecific changes in hepatic and renal function, and
environmental safety. Problems with opioid analgesics are most often caused by improper prescribing practices and inappropriate administration.
Above all, the goal for analgesic therapy should be
acceptable pain relief, not minimal drug doses.24

Cancer Pain

Despite the high incidence of pain,

elders with cancer are less likely to receive aggressive pharmacotherapy, interventional techniques
for pain control, and palliative care services.45 In a
multi-statewide effort to determine the prevalence
of cancer pain and predictors of poor outcomes,
13,625 elders with cancer were evaluated from

19 Chap Cotter

7/2/01

Chapter 19:

4:03 PM

Page 349

349

Pain

hospitalization to long-term care facilities using

the Systematic Assessment of Geriatric Drug Use
via Epidemiology (SAGE) database.46 An alarming
2540% of patients with cancer experienced daily
pain. Lack of adequate analgesia and decreased use
of adjuvant agents for cancer pain were associated
with increased age. Patients of ethnic minorities
were also more likely to be undermedicated. Additionally, as medication regimens for other health
problems became more complex, the use of analgesic therapies was reduced. Preexisting nonmalignant pain problems, cognitive impairment, and
depression were linked to poorer outcomes. A thorough examination of health-care practices in longterm care facilities for recognizing pain, eliciting
self-report outcomes, and prescribing effective
analgesic therapy showed an increased need for
education and change in attitudes and opportunities for maximizing pharmacotherapy in the treatment of cancer pain.46
Patients with cancer not only experience pain
from their disease, but must also contend with
pain from preexisting conditions and cancer therapies. The complex nature of pain associated with
cancer and other factors requires a thorough evaluation of all possible sources of pain. Figure 195
provides an algorithm for specific pain management practices. The World Health Organization
has established a three-step analgesic ladder intended to guide the selection of pharmacological
therapy based on varying levels of pain (Figure
196). The Management of Cancer Pain Guideline
Panel outlines the advantages and disadvantages
of specific pain therapies.23

Opioid Analgesics

Opioid analgesics are indicated when chronic moderate to severe pain has
not responded to nonopioid preparations. Elders
with longstanding chronic pain usually require
opioid therapy. Centrally acting opioid-agonists
(e.g., codeine, hydrocodone, oxycodone, morphine,
hydromorphone) have an affinity for receptors
and are preferred over other opioid preparations.
Opioids, such as mepridine (Demerol) and propoxyphene (active agent in Darvocet), are weak,
and toxic metabolites from these drugs accumulate with repeated dosing. The toxic metabolite of

meperidine, normeperidine, can lead to seizures;

cardiac toxicity may occur from the metabolite of
propoxyphene.37,41 Even with its serious limitations, propoxyphene is still overprescribed and it
is no better in its analgesic efficacy than acetaminophen or aspirin.37
Guidelines for Opioid Therapy

Start low and go slow:6 begin with lower

doses of less-potent, short-acting opioids
such as codeine, hydrocodone (Vicodin,
Lotabs), oxycodone alone, or oxycodone +
acetaminophen (Percocet, Roxicet, Endocet).
Be aware of analgesic peak effects from opioids and duration: a trial of short-acting
opioids at half the usual starting dose for
adults should be initiated. Peak effects from
the opioid may be heightened in elders and
duration extended. Initial prescribing should
allow for longer dosing intervals until
response to the opioid has been evaluated.
Avoid opioids that possess active metabolites or a long half-life: opioids that have
active toxic metabolites (e.g., propoxyphene
and meperidine) should not be used on a
long-term basis. Morphine does have active
metabolites, so it should be administered
with caution. In addition, opioids with
extended T12 (half-life) should not be prescribed for elders who are opioid-nave.
Consider combination opioid preparations
for relief of mild to moderate pain: combination opioid products (e.g., codeine + acetaminophen [Tylenol #3, #4], hydrocodone +
acetaminophen [Vicodin, Lortabs, Lorcet],
oxycodone + acetaminophen [Percocet,
Roxicet, Endocet]) should be prescribed on
a short-term basis for mild to moderate
pain. Overuse of these medications can lead
to acetaminophen hepatotoxicity.
Consider lower doses of short-acting opioid
without combination products: short-acting
oxycodone (Oxy IR, OxyFast) or hydromorphone (Dilaudid) may be appropriate for
patients experiencing severe pain as these
preparations can be titrated to pain relief with-

19 Chap Cotter

7/2/01

4:03 PM

352

Page 352

Part 3:

Avoid the use of other psychoactive drugs:

the concurrent use of other psychoactive
drugs, particularly if initiated with opioids
or close to the time of starting therapy with
opioids, obscures assessment of the untoward effects of opioids. If adjuvant agents
for pain must be initiated, it is best to introduce agents singly and allow ample time (at
least several days) before giving a new agent
with potential psychoactive effects.
Manage opioid-related side effects: the major
side effect of opioids in the elderly is constipation. Mild laxatives such as milk of
magnesia, senna preparations (Senokot), casanthranol and docusate (Pericolace), lactulose, or bisacodyl (Dulcolax) should be
started when opioids are initiated. Stool softeners alone do little or nothing to alleviate
opioid-induced constipation. Unlike many
other adverse effects from opioids, patients
do not develop tolerance to the effects of
opioids on the bowel; therefore, continued
use of laxatives is necessary as long as opioid
therapy is maintained. Consult the American
Geriatrics Society report on the management
of chronic pain in older persons for further
information on analgesic dosing guidelines
and strategies for treating opioid-induced
side effects.6 Published equianalgesic guidelines are often helpful in understanding opioid equivalents and potency, and essential
for safe dosing when switching patients from
one opioid to another.6,23,24,37

Nonopioid Analgesics

Nonopioid analgesics
offer an acceptable alternative to opioid analgesics
for both acute and chronic pain.47,48,49 Nonopioids
are indicated for cancer pain that is considered mild
to moderate resulting from metastatic disease to the
bones; mechanical compression of tendons, muscles,
pleura, and peritoneum; and soft-tissue pain. These
agents are quite effective in the management of noncancer-related pain, such as musculoskeletal pain
caused by arthritis, back pain, and orthopedic
injuries. Nonopioid analgesics are classified based
on their chemical structure and grouped into distinct
categoriespara-aminophenol derivatives (e.g.,

Functional and Clinical Problems Associated with Frailty

acetaminophen [Tylenol]), salicylic acid derivatives

(e.g., aspirin and choline magnesium trisalicylate
[Trilisate]), and a variety of subclasses of other nonsteroidal anti-inflammatory drugs (NSAIDs). Most
of these drugs have antipyretic and analgesic properties that are a result of analgesic effects that occur
in the periphery. Para-aminophenol derivatives such
as acetaminophen do not have anti-inflammatory
properties. While nonopioid drugs are not capable
of producing physical dependence, tolerance, or
addiction, they do have maximum ceiling effects
for their analgesic potential. Higher doses of these
medications often lead to serious side effects.
Acetaminophen and choline magnesium trisalicylate
have no antiplatelet actions; however, the NSAIDs
and aspirin do alter platelet function and coagulation. This potential hematological effect is caused by
irreversible acetylation of platelet cyclooxygenase,
which inhibits platelet aggregation.

Acetaminophen Acetaminophen is recommended

for mild to moderate pain. While effective for
some types of pain (e.g., headache, minor arthritis,
and joint and other muscular pain), it is rarely
effective as a single agent for moderate to severe
pain associated with disease (e.g., cancer, severe
rheumatoid arthritis) or other painful conditions
(e.g., herpes zoster-related pain, compression fractures, severe osteoarthritis).
Recommendations for the Use of Acetaminophen

Daily dose should not exceed 4,000 mg in

elders;6 more prudent use of acetaminophen
would restrict doses to 3,000 mg per day.
Instruct patients about the amount of acetaminophen in combination opioid products
(e.g., Tylenol #2, #3, #4, Darvocet, Vicodin,
Lortabs, Lorcet, Percocet, Roxicet, and
Endocet) in order to avoid acetaminophen
toxicity.
Caution patients about supplementing acetaminophen-opioid combinations with additional acetaminophen.
Acetaminophen alone is not an adequate
rescue drug for supplementing longacting opioid preparations such as trans-

19 Chap Cotter

7/2/01

Chapter 19:

4:03 PM

Page 353

353

Pain

dermal fentanyl (Duragesic), controlledrelease morphine (MSContin), or controlled-release oxycodone (OxyContin).

NSAIDs and Salicylates

The mechanism of
action for these drugs has been well described. The
NSAIDs inhibit cyclo-oxygenase in peripheral tissues, which prevents arachidonic acid from converting to prostaglandin.50 Prostaglandins are associated
with pain that results from injury or inflammation,
and they can sensitize pain receptors to mechanical
and chemical stimulation. The action of these drugs
alters the effects of prostaglandins on the nociceptors
or pain receptors of primary afferents that transmit
pain. NSAIDs, alone or in combination with opioids,
can be helpful in the management of pain from bony
metastases. As tumors invade the bone, prostaglandins are released that sensitize nociceptors and
increase pain. The combination of nonopioids and
opioids administered simultaneously may enhance
analgesia.49
The benefits of NSAIDs must be weighed against
their risk. Commonly, NSAIDs are prescribed for
pain that may not have inflammation as its etiology,
resulting in unnecessary use and lack of analgesic
efficacy. NSAIDs have been linked to serious side
effects in the elderly, including gastrointestinal toxicity.51,52,53 Elderly women are twice as likely to
develop gastrointestinal problems from NSAIDs as
men; furthermore, the elderly in general are at
much greater risk for adverse effects from these
drugs. Extreme caution must also be used with concurrent use of oral anticoagulants and steroids, as
these drugs pose additional risks for serious gastrointestinal side effects. A 13-fold increase in
hemorrhagic peptic ulcer disease was found when
NSAIDs were prescribed to elders on oral anticoagulants.52 Hyperkalemia, renal insufficiency, and
altered cognition have been frequently observed
in elders.54 Celecoxib (Celebrex) and rofecoxib
(Vioxx), which are relatively new agents marketed
for arthritis pain, are specific cyclo-oxygenase-2
inhibiting NSAIDs exerting reduced effects on the
gastrointestinal system. Buffum and Buffum provide a comprehensive review of the properties of
NSAIDs, indications, dosing guidelines, and precautions with use in elders.55 They stress that there

are no acceptable criteria to predict which agents

will work best in patients with pain. Whatever
NSAID is selected, it is recommended the lowest
dose possible be prescribed to elders and the duration of therapy be short. It is often necessary to
allow one to three weeks of therapy for a maximum
effect, before doses are escalated.55
Recommendations for Use of NSAIDs

Avoid high-dose long-term use.

For chronic pain, administer on a prn basis.
Short-acting agents are preferred to avoid
accumulation.
Do not administer with renal dysfunction.
Avoid concurrent use with other antiinflammatory agents (e.g., steroids, other
NSAIDs).
Use one agent at a time.
Avoid concurrent use with anticoagulants
such as warfarin (Coumadin), as the risk for
hemorrhagic ulcer disease is increased.
Do not administer with a history of peptic
ulcer disease.
Remain within the recommended dosing
guidelines; increased doses may not have
added efficacy and may be associated with
significant toxicities.

Steroids Corticosteroids can be useful for treating certain pain syndromes caused by cancer, such as
bony metastases and nerve compression. They may
also provide short-term pain relief and allow more
time to increase opioid analgesic doses. Dexamethasone in doses of 46 mg q 6 hr can be initiated
for 13 days, followed by a slow taper over 710
days.23 Low-dose steroid therapy can be an effective
adjuvant agent for pain from bony metastases.49
Steroids can also be used to treat pain from
rheumatoid arthritis. A recent meta-analysis of
the literature on short-term low-dose steroids and
NSAIDs in the treatment of rheumatoid arthritis
showed that a short course of low-dose, daily prednisolone (15 mg or less) was superior to NSAIDs
in relieving pain and joint tenderness.56 Ten studies were analyzed which revealed that measurable

19 Chap Cotter

7/2/01

4:03 PM

Page 354

354

Part 3:

gains in pain relief and alleviation of joint tenderness were achieved with prednisolone compared
to NSAID therapy.

Other Adjuvant Agents

Tricyclic Antidepressants Tricyclic antidepressants have demonstrated efficacy in the treatment
of neuropathic pain syndromes. The subclass of
tricyclic antidepressants that are tertiary amines
(e.g., amitriptyline) are typically associated with
greater anticholinergic effects, sedation, and orthostatic hypotension. The secondary amines (e.g.,
nortriptyline, desipramine) tend to produce lesssevere adverse effects and may be safer in the frail
elderly.11,37,49 If tricyclic antidepressants are used
for pain, it is often necessary to titrate up to doses
of 75 mg per day or greater before a substantial
benefit for neuropathic pain is observed. This is
often difficult, as the adverse effects from these
agents often limit adequate dosing. Table 193

Table 193

Functional and Clinical Problems Associated with Frailty

outlines important information about the use of

tricyclic antidepressants for neuropathic pain.31
Providing a safe environment is paramount
when any psychoactive drug is prescribed for the
elderly. In a case-control study of tricyclic antidepressant use, a 60% increase in hip fractures in
persons over the age of 65 was reported.57 Body
mass, problems with ambulation, functional status, and dementia did not affect the results; thus,
caution is warranted when prescribing and administering any psychoactive agents. Elders living
alone or in independent assisted-living settings
may require close supervision if tricyclic therapy
is initiated.
Anticonvulsants Anticonvulsant agents, such as
carbamazepine (Tegretol), gabapentin (Neurontin),
phenytoin (Dilantin), valproate and clonazepam
(Klonopin), are particularly effective for neuropathic
pain syndromes associated with shooting, electric
shock-like, or lancinating sensations.11 Table 194

Properties of Common Tricyclic Antidepressants Used as Analgesics for Neuropathic Plan

Usual Daily
Therapeutic
Dosing
Range

Drugs

Relative
Anticholinergic
Effects

Relative
Sedative
Effects

Usual
Starting
Dose

Tertiary amine agents

Amitriptyline

++++

++++

1025 mg 50150 mg
at hs

3045

Doxepin

++

+++

1025 mg 50150 mg
at hs

825

Secondary amine agents

Desipramine
+

25 mg
at hs

100150 mg 1225

Nortriptyline

++

25 mg
at hs

100150 mg 1845

++

Half-Life
(hr)

Comments
Lower initial doses and
gradual titration for
elders.
Risk for orthostatic
hypotension moderate
to high.
Increased risk for
constipation.

Lower toxicity profile.

Recommended for
elderly patients.

19 Chap Cotter

7/2/01

Chapter 19:

4:03 PM

Page 355

355

Pain

Table 194
Drug

Anticonvulsants for Pain Management

Dose

Indications

Adverse Effects

Carbamazepine 100200 mg PO bid

Useful for paroxysmal and lan- Sedation, drowsiness, diplopia,
Increase every other day to 800 cinating, shooting, electric
ataxia, hematological toxicity
mg/day in divided doses.
shock-like pains
Clonazepam

0.51.5 mg/day PO
Maximum 34 mg/day in
divided doses.

Same as above
Useful for preexisting anxiety

Gabapentin

300900 mg tid
Same as above
(9002400 mg) PO
Initial dose 100 mg tid,
then increase by 100 mg/day
as tolerated.
May titrate up to 3600 mg/day.
For elders, increase slowly:
100 mg/day q35 days.

Sedation, ataxia, dizziness,

difficulty concentrating, visual
abnormalities

Phenytoin

300500 mg/day PO.

Same as above

Sedation, drowsiness, ataxia,

diplopia, nausea, skin rash, or
hypertrichosis

Valproic acid

1560 mg/kg/day PO
in divided doses.

Same as above

Behavioral, mood, or mental

changes; hepatotoxicity, visual
disturbances, coagulopathy or
thrombocytopenia, bleeding

provides dosing guidelines and clinical information

on the use of some of these agents.31 Gabapentin
(Neurontin) may have significant advantages over
other anticonvulsants because of its relatively low
toxicity. Unlike carbamazepine and clonazepam,
gabapentin is less sedating. In addition, gabapentin
does not have the hematological effects that are a
concern with carbamazepine and phenytoin. Somnolence, dizziness, ataxia, fatigue, and cognitive dysfunction have been linked to gabapentin, but many
of these adverse effects can be prevented with careful upward titration of the drug. Begin with 100 mg
at hs for 35 days. If no adverse effects, increase the
dose to 100 mg in AM and PM for 35 days, then 100
mg tid for 35 days. Continue escalating the dose by
100 mg per day every 35 days. Typically, patients
require at least 9001,200 mg per day; however,

Sedation, ataxia, behavioral

disturbances, mood or mental
changes

higher daily doses of 2,4003,600 mg have been

suggested to maximize pain control.58,59,60

Topical Agents

Capsaicin, manufactured from

hot peppers, is a safe and effective analgesic agent
offering a wide range of uses for the treatment of
pain from arthritis, herpes zoster, diabetic neuropathy, and mastectomy.61 Capsaicin reduces
inflammation and the cutaneous hypersensitivity
accompanying musculoskeletal pain and neuralgias and neuropathies. When applied regularly to
the skin over painful areas, capsaicin depletes the
nerve terminals of substance P, a peptide responsible for pain transmission. The first few applications often increase pain, but over time (typically a
few days), pain and hypersensitivity of the skin
may subside. A topical anesthetic used with a

19 Chap Cotter

356

7/2/01

4:03 PM

Page 356

Part 3:

lower concentration of capsaicin cream or lotion

may alleviate discomfort and improve compliance
with initial therapy. Capsaicin is available in nonprescription strengths of 0.025% (Zostrix Cream,
Capsaicin-P Cream, and Capsin Lotion) and
0.075% (Zostrix-HP Cream, Capsin Lotion).
After applying capsaicin, hands must be thoroughly washed and affected areas of the skin
should not be touched.
EMLA Cream (product of prilocaine and lidocaine) is a topical agent that reduces the cutaneous
hypersensitivity associated with neuropathic pain.
Once applied, the affected area is covered with an
occlusive transparent dressing such as Tege-Derm,
Op-Cite, or even plastic wrap. While the efficacy
of topical NSAIDs has not been established, various preparations (e.g., ketoprofen gel) are compounded for individual use.

Combining Opioids and Adjuvant Agents for

Neuropathic Pain Syndromes Neuropathic
pain syndromes appear to be less responsive to
opioid analgesics than somatic and visceral pain.
This is an important consideration when prescribing opioid analgesics, as opioid requirements may
be greater for patients with neuropathic pain. If
indicated, opioid therapy can be slowly titrated
upward to the point that patients get relief or
experience intolerable toxicities (e.g., sedation,
nausea). Selection of opioid analgesics is critical,
and those without nonopioid combinations should
be considered so that doses can be escalated without added toxicities from the nonopioid drug (e.g.,
acetaminophen). Greater benefits may be derived
from combining an opioid analgesic with effective
adjuvant agents such as tricyclic antidepressants
and anticonvulsants that have documented efficacy
in the treatment of neuropathic pain. In some
cases, adjuvant therapy alone is effective in relieving neuropathic pain. Selective interventional
techniques including temporary nerve blocks, neurolysis or nerve destruction procedures, and neuraxial (epidural or subarachnoid) therapy have
demonstrated significant benefits.11
Postherpetic neuralgia, more recently classified
as herpes zoster-related pain, is an example of a
neuropathic pain syndrome that persists at least

Functional and Clinical Problems Associated with Frailty

three months after the acute onset of herpetic skin

lesions. Elders are commonly and most severely
afflicted with pain following infection from the
herpes zoster virus with approximately 50% of all
sufferers over the age of 65.62 Patients may be
evaluated in pain clinics for injections of local
anesthetic; however, the benefits are short-term.
Early treatment with corticosteriods and preemptive therapy with tricyclic antidepressants have
minimized the occurrence of persistent pain. In a
recent randomized-controlled study comparing
amitriptyline and nortriptyline, efficacy for pain
control was similar, although fewer side affects
were associated with nortriptyline.63 Controlledrelease oxycodone has also demonstrated significant benefits to placebo in relieving paroxysmal
spontaneous pain and cutaneous hypersensitivity.64
Topical agents, such as capsaisin and EMLA cream,
are also helpful for allodynia (pain from stimuli
that are not generally considered painful) of the
skin along the distribution(s) of nerve involvement.

Nonpharmacological Approaches
for Pain
Nonpharmacological approaches for pain control
can be useful adjuncts to analgesic therapy, reducing the need for drug therapy and improving overall well being. Such approaches provide a sense of
personal control and offer relief during times when
medication is not available. Nonpharmacological
approaches should not replace analgesic therapy
for disease-related pain as relief may be highly
variable and unlikely to be sustained long-term.
Importantly, it is essential to recognize both the
advantages and disadvantages of nonpharmacological pain therapies (Table 195).31
Cutaneous Stimulation
Heat and cold therapies offer short-term relief of
acute or chronic musculoskeletal pain. Heat is
applied with hot packs and heating pads to achieve
muscle and generalized relaxation. Elders need to
be aware of potential tissue damage from heat,
especially if skin sensation is impaired. The application of heat on or near the area of a transdermal

19 Chap Cotter

7/2/01

Chapter 19:

Table 195

4:03 PM

Page 357

357

Pain

Selected Nonpharmacological Interventions for Pain

Technique

Examples

Advantages

Disadvantages

Cutaneous
stimulation

Superficial heating
or cooling,
vibration, massage

Many methods; makes pain

tolerable, reduces pain, patients
are receptive; can apply stimulation at site of pain or other sites;
can provide distraction

Not for therapeutic or curative

purposes; can damage tissue if
applied incorrectly

Immobilization/
mobilization

Splinting, bracing,
walking, exercise,
rest

Decreases pain, improves range

of motion, conserves energy,
improves functional status,
promotes relaxation

Discomfort on physical exertion;

decrease in functional status

Distraction

Internal: Mental
images, counting,
singing silently;
external: music,
reading, television,
conversation

Decreased pain intensity,

increased pain tolerance; more
acceptable pain sensation;
greater sense of control;
improved mood

Not helpful for vigilant patients; may

have no effect on pain intensity; may
be hard to enact; may not look like
they are in pain resulting in doubt
about pain and/or failure to medicate
after distraction; awareness of pain
and fatigue may increase; irritability

Relaxation

Slow breathing,
progressive muscle
relaxation, relaxing
mental imagery,
repetitive activity
or thought

Reduces anxiety, may reduce

pain; promotes sleep; decreases
fatigue and skeletal muscle
tension; increases confidence
in ability to handle pain

Can be time-consuming; difficult to

teach, practice, and use effectively;
is an adjunct method that does not
directly relieve pain; often difficult
to distinguish between relaxation
and imagery

Comprehensive
models

Cognitive/
behavioral
interventions,
psychoeducational
approaches

Address multiple dimensions

of pain; individualized;
include patient and family;
problem-focused; requires
interdisciplinary team

May be difficult to assemble an

appropriate interdisciplinary team
depending on setting and resources;
can be complex and time-consuming

fentanyl system (Duragesic) is particularly dangerous. Local heat as well as elevated body temperatures can accelerate release and absorption of the
transdermal fentanyl, leading to overmedication
or a serious opioid overdose. In addition to heat,
cold therapy with ice packs and the application of
methanol offer localized relief of pain and swelling
from inflammation.
Massage therapy may relieve superficial and
deep musculoskeletal pain. Massage therapy has a
positive effect on the perceptions of postoperative

pain, with greater duration of pain relief in older

patients.65 Transelectrical nerve stimulation (TENS)
is particularly useful for musculoskeletal pain.66
Application of cutaneous electrodes may be difficult for some elderly patients, making compliance problematic.
Cognitive or Behavioral Therapy
Cognitive or behavioral therapy is aimed at changing beliefs and attitudes toward pain, promoting

19 Chap Cotter

358

7/2/01

4:03 PM

Page 358

Part 3:

adaptive coping, and reducing stress. Cognitive

strategies include distraction, relaxation, visual
imagery, biofeedback, and hypnosis. Behavioral
approaches often rely on group therapy and individual counseling in the context of a structured
program. Significant benefits have been achieved
with cognitive and behavioral approaches. For
example, cognitive-behavioral programs have had
lasting effects on adaptive coping and improvement
in fatigue with rheumatoid arthritis.67 The mechanism for pain relief with cognitive or behavioral
therapies, particularly relaxation, remain unclear,
and to date the evidence is insufficient to conclude
that relaxation therapy reduces chronic pain.68
For those interested in cognitive or behavioral
therapies for pain, resources must be available (e.g.,
access to programs or trained professionals), and
motivation and emotional stamina are needed to
learn and practice the techniques. Such strategies
may have little benefit for elders who are suffering
from pain, debilitated, or cognitively impaired and
unable to concentrate. This is especially true in
long-term care facilities.
Exercise
Exercise is an inexpensive way to restore muscle and
joint function, while decreasing pain associated with
immobility. Apparently, isokinetic muscle-strengthtraining programs for persons with osteoarthritis of
the knees decreases pain and stiffness and improves
mobility and muscle strength.69 Exercise programs
should be tailored to specific needs, abilities, and
activity tolerance levels, especially in the presence of
cardiac disease. Consultation with physical or occupational therapists is critical to avoid risks of exercise-induced injuries. Swimming and water aerobics
are especially useful for elders with degenerative
joint disease, rheumatoid arthritis, and osteoporosis
who might otherwise experience significant pain
with weight-bearing exercises.
The treatment of chronic nonmalignant pain is
controversial, but experts agree that a multimodality
approach using a combination of pharmacotherapy
and physical and psychosocial interventions is better
than any one alone. While there may be reluctance
to treat noncancer pain with opioid analgesics, this

Functional and Clinical Problems Associated with Frailty

is certainly an acceptable and effective method of

treatment when the underlying cause of the pain
cannot be reversed or other strategies have failed.

Summary
There is substantial evidence to support that pain is a
common experience among elders and that health
professionals have a responsibility to evaluate pain
and treat it appropriately. Evidence- and consensusbased information, which has recently become accessible through published research and clinical practice
guidelines, is the best defense against the problem of
pain as experienced by older people. Nurses make an
enormous contribution to patients by allowing them
to express their pain and implementing sound pharmacological and nonpharmacological therapies.

References
1. Liebeskind JC, Melzack R. The International Pain
Foundation: meeting a need for education in pain.
J Pain Symptom Manage. 1988;3(3):131134.
2. Gagliese L, Melzack R. Chronic pain in elderly people.
Pain. 1997;70:314.
3. Herr KA, Mobily PR. Complexities of pain assessment
in the elderly. Clinical considerations. J Gerontol Nurs.
1991;17(4):1219.
4. Ferrell BA. Pain in elderly people. J Am Geriatr Soc.
1991;39:6473.
5. Stein M, Ferrell BA. Pain in the nursing home. Clin
Geriatr Med. 1996;12:601613.
6. American Geriatrics Society Panel on Chronic Pain in
Older Persons. The management of chronic pain in
older persons. J Am Geriatr Soc. 1998;46:635651.
7. Roy R, Thomas MR. Elderly persons with and without
pain: a comparative study. Clin J Pain. 1987;3:
102106.
8. Desbiens NA, Mueller-Rizner N, Connors AF Jr,
Hamel MB, Wenger NS. Pain in the oldest-old during
hospitalization and up to one year later. J Am Geriatr
Soc. 1997;45(10):11671172.
9. Ferrell BA, Ferrell BR, Osterweil D. Pain in the
nursing home. J Am Geriatr Soc. 1990;38:409414.
10. Parker SL, Tong T, Bolden S, Wingo PA. Cancer
statistics, 1996. CA Cancer J Clin. 1996;46:527.
11. Lipman AG. Analgesic drugs for neuropathic and
sympathetically maintained pain. Clin Geriatr Med.
1996;12:501515.
12. Bennett GJ. Neuropathic pain. In: Wall PD, Melzack
R, eds. Textbook of Pain, 3rd ed. New York: Churchill
Livingstone; 1994:261274.

19 Chap Cotter

7/2/01

Chapter 19:

4:03 PM

Page 359

Pain

13. Ward SE, Goldberg N, Miller-McCauley V, et al.

Patient-related barriers to the management of cancer
pain. Pain. 1993;23(4):319324.
14. Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its
treatment in outpatients with metastatic cancer: the
Eastern Cooperative Oncology Groups Outpatient
Pain Study. N Eng J Med. 1994;330(9):592596.
15. Ferrell BA, Ferrell BR, Rivera L. Pain in the cognitively
impaired nursing home patient. J Pain Symptom
Manage. 1995;10:591598.
16. Brockopp DY, Warden S, Colclough G, Brockopp G.
Elderly hospice patients perspective on pain
management. Hospice J. 1996;11(3):4153.
17. Horgas AL, Tsai PF. Analgesic drug prescription and
use in cognitively impaired nursing home residents.
Nurs Res. 1998;47(4):235242.
18. Parmelee PA, Smith B, Katz IR. Pain complaints and
cognitive status among elderly institution residents.
J Am Geriatr Soc. 1993;41:517522.
19. Von Roenn JH, Cleeland CS, Gonin R, Hatfield AK,
Pandya KJ. Physician attitudes and practice in cancer
pain management: a survey from the Eastern
Cooperative Oncology Group. Ann Intern Med.
1993;119:121126.
20. Brunier G, Carson MG, Harrison DE. What do nurses
know and believe about patients with pain? Results
of a hospital survey. J Pain Symptom Manage. 1995;
10(6):436445.
21. Simon JM, McTier CL. Development of a chronic pain
assessment tool. Rehabil Nurs. 1996;21:2024.
22. Acute Pain Management Guideline Panel. Clinical
Practice Guidelines: Acute Pain Management:
Operative or Medical Procedures or Trauma.
Rockville, Md: Agency for Health Care Policy and
Research, US Department of Health and Human
Services; 1992. AHCPR Publication 920032.
23. Management of Cancer Pain Guideline Panel. Clinical
Practice Guidelines Number 9: Management of Cancer
Pain. Rockville, Md: Agency for Health Care Policy
and Research, US Department of Health and Human
Services; 1994. AHCPR Publication 940592.
24. American Pain Society. Principles of Analgesic Use in
the Treatment of Acute Pain and Cancer Pain. 4th ed.
Skokie, Il: American Pain Society; 1999.
25. Herr KA, Mobily P. Comparison of selected pain
assessment tools for use with the elderly. Appl Nurs
Res. 1993;6:3946.
26. Herr KA, Mobily PR, Kohout FJ, Wagenaar D.
Evaluation of the faces pain scale for use with elderly.
Clin J Pain. 1998;14(1):2938.
27. Bieri D, Reeve RA, Champion GD, Addicoat L,
Ziegler JB. The Faces Rating Scale for self-assessment
of the severity of pain experienced by children:
development, initial validation, and preliminary
investigation for ration scale properties. Pain.
1990;41:139150.

359
28. Daut RL, Cleeland CS, Flanery RC. Development of
the Wisconsin brief pain questionnaire to assess pain
in cancer and other diseases. Pain. 1983;17:197210.
29. Melzack R. The short-form McGill Pain
Questionnaire. Pain. 1987;30:191197.
30. Weiner D, Pieper C, McConnell E, Martinez S, Keefe
F. Pain measurement in elders with chronic low back
pain: traditional and alternative approaches. Pain.
1996;67(23):461467.
31. Polomano RC, McGuire DB, Sheidler VR. Pain
(part II). In: Yarbro CH, Frogge MH, Goodman M,
Groenwald SL, eds. Cancer Nursing: Principles and
Practice. 5th ed. Sulbury, Mass: Jones and Barlett;
2000:657690.
32. Dellasega C, Keiser CL. Pharmacologic approaches
to chronic pain in the older adult. Nurse Pract. 1997;
22(5):2024.
33. Gloth FM. Concerns with chronic analgesic therapy
in elderly patients. Am J Med. 1996;101(suppl 1A):
19S24S.
34. Pope JE, Anderson JJ, Felson DT. A meta-analysis of
the effects of nonsteroidal anti-inflammatory drugs on
blood pressure. Arch Intern Med. 1993;153:477484.
35. Ruoff G. Management of pain in patients with
multiple health problems: a guide for the practicing
physician. Am J Med. 1998;105(Suppl 1B):53S60S.
36. Yost JH, Morgan CJ. Cardiovascular effects of
NSAIDs. J Musculoskel Med. 1994;11:2234.
37. United States Pharmacopeial Convention. USP DI
Drug Information for the Health Care Professional.
19th ed. Englewood, Co: Micromedex; 1999.
38. Lynch EP, Lazor, MA, Gellis, JE, Orav J, Goldman L,
Marcantonio ER. The impact of postoperative pain
on the development of postoperative delirium. Anesth
Analg. 1998;86:781785.
39. Richardson J, Bresland K. The management of
postsurgical pain in the elderly population. Drugs
Aging. 1998;13(1):1731.
40. Egbert AM, Parks LH, Short LM, Burnett ML.
Randomized trial of postoperative patient-controlled
analgesia vs. intramuscular narcotics in frail elderly
men. Arch Intern Med. 1990;150:18971903.
41. Plummer JL, Owen H, Ilsley AH, Inglis S. Morphine
patient-controlled analgesia is superior to meperidine
patient-controlled analgesia for postoperative pain.
Anesth Analg. 1997;84:794799.
42. Wulf H. Epidural analgesia in postoperative pain
therapy: a review. Anaesthetist. 1998;47(6):501510.
43. Scott DA, Emanuelsson BM, Mooney PH, Cook RJ,
Junestrand C. Pharmacokinetics and efficacy of longterm epidural ropivacaine infusion for postoperative
analgesia. Anesth Analg. 1997;85:13221330.
44. Abrahm JL. Advances in pain management for older
adult patients. Clin Geriatr Med. 2000;16(2):269311.
45. Cleary JF, Carbone PP. Palliative medicine in the
elderly. Cancer. 1997;80(7):13351347.

19 Chap Cotter

360

7/2/01

4:03 PM

Page 360

Part 3:

46. Bernabei R, Gambassi G, Lapane K, et al. Management

of pain in elder patients with cancer. SAGE study
group. Systematic assessment of geriatric drug use via
epidemiology. JAMA. 1998;279(23):18771882.
47. Schnitzer TJ. Non-NSAID pharmacological treatment
options for the management of chronic pain. Am J Med.
1998;105(1B):45S51S.
48. Beaver WT. Impact of non-narcotic oral analgesics on
pain management. Am J Med. 1988;84(5A):315.
49. Portenoy RK, Kanner RM. Nonopioid and adjuvant
analgesics. In: Portenoy RK, Kanner RM, eds. Pain
Management: Theory and Practice. Philadelphia:
F.A. Davis; 1996:219276.
50. Insel PA. Analgesic-antipyretic and antiinflammatory
agents: drugs employed in the treatment of gout. In:
Hardman JG, Gilman AG, Limbard LE, et al, eds.
Goodman and Gilmans The Pharmacological Basis
of Therapeutics. 9th ed. New York: McGraw-Hill;
1996;617657.
51. Tamblyn R, Berkson L, Dauphinee WD, et al. Unnecessary
prescribing of NSAIDs and the management of NSAIDrelated gastropathy in medical practice. Ann Intern Med.
1997;127(6):429438.
52. Shorr RI, Ray WA, Daugherty JR, Griffin MR.
Concurrent use of nonsteroidal anti-inflammatory
drugs and oral anticoagulants places elderly persons at
high risk for hemorrhagic peptic ulcer disease. Arch
Intern Med. 1993;153(14):16651670.
53. Smalley WE, Ray WA, Daugherty JR, Griffin MR.
Nonsteroidal anti-inflammatory drugs and the
incidence of hospitalizations for peptic ulcer disease in
elderly persons. Am J Epidemiol. 1995;141(6):539545.
54. Sack KE. Update on NSAIDs in the elderly. Geriatrics.
1989;44:7190.
55. Buffum M, Buffum JC. Nonsteroidal antiinflammatory drugs in the elderly. Pain Manage Nurs.
2000;1(2):4050.
56. Gotzsche PC, Johansen HK. Meta-analysis of shortterm prednisolone versus placebo and non-steroidal
anti-inflammatory drugs in rheumatoid arthritis. BMJ.
1998;316(7134):811818.
57. Ray WA, Griffin MR, Malcolm E. Cyclic antidepressants
and the risk for hip fractures. Arch Intern Med. 1991;
151:754756.

Functional and Clinical Problems Associated with Frailty

58. Wetzel CH, Connelly JF. Use of gabapentin in pain

management. Ann Pharmacother. 1997;31(9):
10821083.
59. Backonja M, Beydoun A, Edwards KR, et al.
Gabapentin for the symptomatic treatment of painful
neuropathy in patients with diabetes mellitus: a
randomized controlled trial. JAMA. 1998;280(21):
18311836.
60. Rowbotham M, Harden N, Stacey B, Bernstein P,
Magnus-Miller L. Gabapentin for the treatment of
postherpetic neuralgia: a randomized controlled trial.
JAMA. 1998;280(21):18371842.
61. Hautkappe M, Roizen MF, Toledano A, Roth S,
Jeffries JA, Ostermeier AM. Review of the
effectiveness of capsaicin for painful cutaneous
disorders and neural dysfunction. Clin J Pain.
1998;14(2):97106.
62. Bowsher D. The management of postherpetic
neuralgia. Postgrad Med J. 1997;73(864):623629.
63. Watson CP, Vernich L, Chipman M, et al. Nortriptyline versus amitrityline in postherpetic neuralgia: a
randomized study. Neurology. 1998;51(4):11661171.
64. Watson CP, Babul N. Efficacy of oxycodone in
neuropathic pain: a randomized trial in postherpetic
neuralgia. Neurology. 1998;50(6):18371841.
65. Nixon M, Teschendorff J, Finney J, Karnilowicz W.
Expanding the nursing repertoire: the effects of
massage on post-operative pain. Austr J Adv Nurs.
1997;14(3):2126.
66. Griffin MR, Brandt KD, Liang MH, Pincus T,
Ray WA. Practical management of osteoarthritis:
integration of pharmacologic and nonpharmacologic
measures. Arch Fam Med. 1995;4(12):10491055.
67. Sinclair VG, Wallston KA, Dwyer KA, Blackburn DS,
Fuchs H. Effects of cognitive-behavioral intervention
for women with rheumatoid arthritis. Res Nurs
Health. 1998;21(4):315326.
68. Carroll D, Seers K. Relaxation for the relief of chronic
pain: a systematic review. J Adv Nurs. 1998;27(3):
476487.
69. Schilke JM, Johnson GO, Housh TJ, ODell JR.
Effects of muscle-strength training on the functional
status of patients with osteoarthritis of the knee joint.
Nurs Res. 1996;45(2):6872.

00 Cotter FM

7/2/01

3:48 PM

Page xi

Contributors

Sherry Greenberg, MSN, RN, CS

Clinical Assistant Professor
Gerontological Nurse Practitioner and Coordinator
Advanced Practice Nursing: Geriatric Program
Division of Nursing, School of Education
New York University
New York, New York
Kathleen A. Hill-ONeill, MSN, RN, CS, NHA
Gerontological Nurse Practitioner and Administrator
Rydal Park
Rydal Park, Pennsylvania
Sarah H. Kagan, PhD, RN
Assistant Professor of Gerontological Nursing
School of Nursing, University of Pennsylvania
Philadelphia, Pennsylvania
Mary F. Kelley, MSN, RN, CS
Geriatric Nurse Practitioner
Center for Senior Health Care
Cherry Hill, New Jersey
Lenore H. Kurlowicz, PhD, RN
Assistant Professor of Geropsychiatric Nursing
School of Nursing, University of Pennsylvania
Philadelphia, Pennsylvania
Barbara J. Maschak-Carey, MSN, RN
Diabetes Clinical Nurse Specialist
University of Pennsylvania
Philadelphia, Pennsylvania
Rosemary C. Polomano, PhD, RN, FAAN
Senior Researcher
Outcomes, Research, and Informatics
Assistant Professor, Department of Anesthesiology
The Pennsylvania State Milton S. Hershey Medical Center and
Pennsylvania State University College of Medicine
Hershey, Pennsylvania
Alicia A. Puppione, MSN, RN
Santa Monica, California

xi

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.