7/30/2019 Managing Chronic Pain in Older People by Patrcia Schofield

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26 Nrsing Tims 31.07.13/ Vol 109 No 30 / www.nursingtimes.net

Kwrds:Older people/Pain/

Analgesia

This article has been double-blind

peer reviewed

Nursing PracticeGuidance in briefOlder people

Alamy

Atr Patricia Schoeld is proessor o

nursing at University o Greenwich, and

lead o the guideline development group.

Abstract Schoeld P (2013) Managing

chronic pain in older people. Nursing

Times; 109: 30, 26-27.

This article presents the results o a

collaborative project between the British

Pain Society and British Geriatric Society

to produce guidelines on the management

o pain in older adults. The guidelines are

the rst o their kind in the UK and aim to

provide best practice or the management

o pain to all health proessionals working

with older adults in any care setting.

Pain is oten poorly managed inolder people and there is a needor comprehensive guidelines toadvise practitioners on how they

can ensure pain management is tailored tothis group. With this in mind, we haveresearched the literature on pain manage-

ment in older people and used our ndingsto create a set o guidelines, usable by allhealth proessionals working in any set-ting. We chose not to address assessmento pain as this has been published previ-ously and is currently being updated. Theocus is on chronic pain, which is denedas that which persists beyond the expectedhealing time (Merskey and Bogduk, 1994).

MtdgWe searched both PubMed and CINAHLor relevant publications between 1997 and2010. Approximately 5,000 records wereidentied in the initial search and a qualityscore was then assigned to each paper andreviewed independently by anothermember o the group. All papers consid-ered to be acceptable were incorporated

5 keypoints

1Pain is a risk

actr r as indr pp

2It is tgt

tat 50%

dr adts iving

in t cmmnit,

and 80% ts

iving in car

ms, xprinc

crnic pain

3Fw stdis

k at t

cts

parmacgica

intrvntins

spcifca n

dr pp

4Cmbinatin

trap sing

dirnt casss

anagsics ma b

mr ctiv wit

wr sid-cts,

cmpard wit

igr dss a

sing mdicin

5Frtr

rsarc isndd n

pscgica

tratmnts r pain

in dr pp

into matrices and included in the com-mentary. A detailed summary o the searchcriteria is provided in the ull document.

Prvanc painIt is impossible to determine a denitiveprevalence o pain in older people due todierences in the denition o pain, popu-lation and methods o measuring pain.Ater reviewing the literature, we agree

with previous studies that suggest 50% oolder adults living in the community and80% o those living in care homes experi-ence chronic pain. This suggests that ourmost vulnerable, rail members o societyexperience more pain than the generalpopulation.

Pain is more prevalent in older women.The eect o age is inconsistent, with somestudies reporting an increase in prevalence

with age and others reporting a decreasewith age. Prevalence also varies by genderand site o pain. The three most common

sites o pain in older people are the back,leg/knee, hip and other joints.

Parmacgica appracsFew studies have investigated the eects opharmacological interventions on olderpeople. Generally, studies look at interven-tions in younger people and the results aretranslated across the age ranges. Neverthe-less, there are some take-home messages

with pharmacological strategies (Box 1).

Intrvntina trapisInterventional approaches include a varietyo neural blocks and minimally invasiveprocedures. Intra-articular (IA) corticos-teroid injections in knee osteoarthritis areeective in relieving pain in the short term

with ew complications and little joint

In this article...

Rviw t avaiab itratr

Advic n sitab parmacgica intrvntins Gidanc n nn-parmacgica pain managmnt

Pain management needs to be tailored or older people. The British Pain Societyand British Geriatric Society produced guidelines specically or this client group

Managing chronic painin older people

The back is a

common site o pain

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www.nursingtimes.net/ Vol 109 No 30 /Nrsing Tims 31.07.13 27

advocated. The specic type o exercise isprobably less important, but exercise must

be tailored to the unctional level o theindividual. Balance exercises can be incor-porated successully into a programme.

A variety o devices are designed toassist in activities o daily living; however,most studies are descriptive in nature andew have considered pain reduction inolder people. Assistive devices can be usedto support community living, preventunctional decline and reduce care costs.

S-managmntSel-management approaches are beingpromoted or all aspects o care and thesetechniques should be considered with othermethods o pain management. Sel-man-agement programmes with mechanismsor long-term support may have some ben-et, but there is a lack o evidence on pro-

grammes delivered without support.

Cmpmntar trapisThere is limited evidence to support theuse o complementary therapies.

CncsinWe identied only a small number ostudies on the management o pain inolder people. To develop the guideline, it

was necessary to use studies that recruiteda younger population, some o whichincluded people over the age o 65 years.The guideline has exposed this lack o evi-dence or many types o treatment in anever-increasing ageing population. NT

Rrnc

Merskey H, Bogduk N (1994) Taxonomy o Pain

Terms & Defnitions. Seattle: IASP Press

Pscgica intrvntinsPsychological interventions, such as cogni-tive behavioural therapy, may be eective inreducing chronic pain and improving disa-

bility and mood in adults. However, ewstudies ocused on older adults and, wherestudies have been carried out, the samplesizes have been small. There is some evi-dence supporting the use o CBT in nursinghomes and limited evidence that bioeed-

back training, mindulness, meditation andenhancing emotion regulation may be ben-ecial or persistent pain. Although theseapproaches appear to be helpul, there is aneed or urther research in this area.

Psitrap and ccpatinatrap

We know that pain is a risk actor or allsin older people. Programmes that consisto strengthening, fexibility and endur-ance activities to increase physical activityand improve pain and unction are

damage. IA hyaluronic acid is eective withew systemic adverse eects and it should

be considered in patients who are intolerantto systemic therapy. It has a slower onset oaction than IA steroids but the eectsappear to last longer.

Epidural corticosteroid injections orspinal stenosis in older patients may beappropriate, but their use in radicular painor sciatica is not so convincing. Epiduraladhesiolysis or spinal stenosis and radic-ular symptoms may benet older adults.The evidence or acet joint interventionsin all age groups is mixed, although thereis some support or radiorequency dener-

vation o the medial branch nerves inappropriately selected patients.

There is weak evidence or sympathec-tomy or neuropathic pain in older people.A nerve block using a combination o localanaesthetic and corticosteroid is eective

in acute herpes zoster and post-herpeticneuralgia. Botulinum toxin may also be

benecial. Microvascular decompressionis the treatment o choice or trigeminalneuralgia in healthy patients and percuta-neous procedures are indicated or olderpatients with high comorbidity.

There is conficting evidence or verte-broplasty and kyphoplasty in the treatmento painul vertebral ractures and we wereunable to draw a conclusion on their use.

There are no studies o spinal cord stim-ulation specically targeting older people.However, randomised control trials inmixed-aged groups, including over-65s,support its use or selected patients withailed back surgical syndrome, complexregional pain syndrome, and neuropathicand ischaemic pain.

Paracetamol is an eective analgesic,

particularly or musculoskeletal pain. It is

well tolerated, but the recommended

daily dose should not be exceeded.

Non-steroidal anti-inammatory drugs

(NSAIDs) are eective analgesics, but

their side-eect prole means they need

to be used with caution in older people. I

essential, the lowest dose should be used

or the shortest period and it should be

reviewed regularly. A proton pump

inhibitor should be co-prescribed with an

NSAID or selective COX-2 inhibitor.

In the short term, opioids may be

eective or both cancer and non-cancer

pain, but there is a lack o long-term data.Opioids may be appropriate or patients

with moderate or severe pain, particularly

i the pain is causing unctional

impairment or reducing quality o lie.

Treatment must be individualised and

careully monitored or efcacy and

tolerability as individual patients

response to opioids varies considerably.

Side-eects o opioid therapy (including

nausea and vomiting) are common so

suitable prophylaxis should be

considered. Appropriate laxative therapy,

such as the combination o a stool

sotener and a stimulant laxative, should

be prescribed throughout treatment or

all older people prescribed opioid therapy.

Tricyclic antidepressants or anti-

epileptics may be used or neuropathic

pain. Although tricyclic antidepressantsare eective, anti-cholinergic side-eects

may be a problem. Patients should be

started on the lowest possible dose and

this should be increased slowly. There is

limited evidence or the efcacy o other

antidepressants, such as SSRIs, and they

should not be used as analgesics.

The use o older anti-epileptic drugs is

limited by adverse eects and the need

or blood monitoring. Dose adjustment o

gabapentin and pregabalin is required in

renal impairment.

Topical lidocaine and capsaicin have

limited efcacy in managing localised

neuropathic pain and topical NSAIDs

may be suitable or non-neuropathic

pain, particularly i the pain is localised.

Combination therapy using dierent

classes o analgesics may provide greaterpain relie through synergistic action with

ewer side-eects, compared with higher

doses o a single medicine.

Box 1. Key MeSSAGeS FoR PhARMAColoGICAl STRATeGIeS

The ull guidance was published inAge

and Ageing and is available rom:

Pain management guidelines

tinyurl.com/Ageing-pain

Pain assessment guidelines

tinyurl.com/PainSoc-older

Box 2. ReSouRCeS

QuICKFACT

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| 80%People in care homesexperiencing chronic pain

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