Pain in elderly

PAIN IN ELDERLY

Cho Mar Lwin, Chit Soe

18.10.13 Pain-Elderly 1

Pain in the Elderly

• Definition of Pain—An individual’s

unpleasant sensory or emotional

experience

– Acute pain is abrupt usually abrupt in onset

and may escalate

– Chronic pain is pain that is persistent or

recurrent



Age related changes:

Reduction in number and function of peripheral nociceptive neurons.

Sensory threshold for thermal and vibratory stimuli increase with age.

Pain receptors: 50% decrease in Pacini's corpuscles,10%-30% decrease in Meissner's/Merkle's disks

Diminished endogenous analgesic response (endorphins)

in the older patients.

Geriatric medicine: An evidence based approach 4th edition 2003



Peripheral nerves :

Myelinated nerves

Decreased density

Increase abnormal/degenerating fibers

Slower conduction velocity

Unmyelinated nerves

Decreased number of large fibers (1.2-1.6 mm

No change in small fibers (0.4 mm)

Substance P content decreased



Central nervous system

Loss in dorsal horn neurons

Altered endogenous inhibition, hyperalgesia

Loss of neurons in cortex, midbrain, brainstem

18% loss in thalamus

Altered cerebral evoked responses

Decreased catacholamines, acetylcholine,

GABA, serotonin

Endogenous opioids: mixed changes

Neuropeptides: no change


Prevalence of pain in Elderly

1 in 5 elderly have pain

• 18% above 65 are taking pain medications regularly

• One-fifth of adults 65 years and older said they had experienced pain in the past month that persisted for more than 24 hours.

• Almost three-fifths of adults 65 and older with pain said it had lasted for one year or more.

• Women report severely painful joints more often than men (10 percent versus 7 percent).

CDC′s National Center for Health Statistics 2006,


Pain in the Elderly

• The most common reason for unrelieved

pain in the U.S. is failure of staff to

routinely assess for pain

• Therefore, JCAHO has incorporated

assessment of pain into its practice

standards

• “The fifth vital sign”


Return to top.

In 2000 42% of population >65 and over reported long lasting

disability


Pain in the ElderlySources of pain in the nursing home

Source: Stein et al, Clinics in Geriatric

Medicine: 1996Condition causing pain Frequency (%)

Low back pain 40

Arthritis 37

Previous fractures 14

Neuropathies 11

Leg cramps 9

Claudication 8

Headache 6

Generalized pain 3

Neoplasm: 318.10.13 Pain-Elderly 10

Pain in the Elderly

• Degenerative joint

disease

• Gastrointestinal causes

• Fibromyalgia

• Peripheral vascular

disease

• Rheumatoid arthritis

• Post-stroke syndromes

• Low back disorders

• Improper positioning

Conditions Associated with the Development of

Pain in the Elderly


Pain in the Elderly

• Crystal-induced

arthropathies

• Renal conditions

• Gastrointestinal

disorders

• Osteoporosis

• Immobility, contracture

• Neuropathies

• Pressure ulcers

• Headaches

• Amputations

• Oral or dental Pathology

Conditions Associated with the Development of

Pain in the Elderly


Pain in the Elderly: Myths

• To acknowledge pain is a sign of personal

weakness

• Chronic pain is an inevitable part of aging

• Pain is a punishment for past actions

• Chronic pain means death is near

• Chronic pain always indicates the presence of a

serious disease

• Acknowledging pain will mean undergoing

intrusive and possible painful tests.


Pain in the Elderly

Consequences of untreated pain:

• Depression

• Suffering

• Sleep disturbance

• Behavioral disturbance

• Anorexia, weight loss

• Deconditioning, increased falls




Treatment

Age-Related Physiologic Changes

Decreased renal function

Decreased volume of distribution because

of decreased lean body weight

Decreased liver mass and hepatic blood

flow

Decreased activity of some drug-

metabolizing enzymes

Decreased serum protein concentrations 18.10.13 Pain-Elderly 17


Treatment

Nonopioid Analgesics for Older Adults

Acetaminophen:

1)Treatment of choice for Osteoarthritis

2)Exhibits an analgesic ceiling beyond which

higher doses do not provide greater pain

relief.

3) Maximum dose 4 gm/day


Treatment

Nonselective NSAIDs

Inhibit prostaglandin synthesis

Appropriate for short term use

All have ceiling effect

Risk of gastrointestinal bleed, renal

impairment, platelet dysfunction

Selective COX-2 inhibitors (celecoxib is

only one currently available in U.S.)

Reduced gastrointestinal side-effects and 18.10.13 Pain-Elderly 20


http://www.adampease.org/Articulate/SUMOpictures/pictures/plants/assorted/assorted_7/Opium_Poppy.png

http://www.adampease.org/Articulate/SUMOpictures/pictures/plants/assorted/assorted_7/Opium_Poppy.png

Treatment with Opioids

Stimulates mu opioid receptor.

Used for moderate to severe pain.

Used for both nociceptive and neuropathic

pain.

Opioid drugs have no ceiling to their

analgesic effects and have been shown to

relieve all types of pain.

Elderly people, compared to younger

people, may be more sensitive to the

analgesic properties.


Opioids

Morphine

Hepatic metabolism and renally excreted; not dialyzable.

Oral bioavailability 30-40%,

M6G is active metabolite with analgesic activity,

M3G is another metabolite causes neurotoxicity,

Morphine is available in oral (liquid and pill), topical, sublingual, parenteral, intrathecal, epidural and rectal routes.

High doses can lead to myoclonus and hyperalgesia.


Opioids

Oxycodone

Only available in oral form

More potent than morphine

Available as single agent and in combination with NSAIDs and acetamenophen

Available in long-tacting, slow release form – OxyContin)

Methandone

Blocks NMDA receptors, inexpensive, lacks active metabolite

Used for neuropathic pain

Variable(long) half-life, high tissue distribution,

Converting from any opioid to methadone takes several days


Opioids

Hydrocodone (Vicodin, Lortab, Norco, others)

Only available in combination with acetamenophen or NSAID

Hydromorphone (Dilaudid)

5 times more potent than morphine

Not available in long acting preparation

Propoxyphene (darvocet)

very weak analgesic effect, can cause ataxia and neurotoxicity, twofold higher risk of hip fractures.


Non-opioid medications for pain Tricyclic antidepressants ( amytriptyline, desipramine) for

neuropathic pain, depression, sleep disturbance. Not used often due to side-effects.

Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain.

Anticonvulsants ( gabapentin, pregabalin, carbamazepine)

for neuropathic pain. Carbamazepine can be used for trigeminal neuralgia, may cause pancytopenia.

Muscle relaxants : for muscle spasm, monitor for sedation

Local anesthetics (lidocaine patch, topical voltaren gel, capsaicin). Capsaicin depletes substance P, may take weeks to reach full effect, adverse effects include burning and erythema. Lidocain patch FDA approved for post herpetic neuralgia.

Placebos: unethical


Non-opioid treatment

Massage reduces pain, including release of

muscle tension, improved circulation,

increased joint mobility, and decreased

anxiety

TENS unit: Can be considered for diabetic

neuropathy but not for chronic low back

pain


Non-drug treatment

Education: basic knowledge about pain (diagnosis, treatment, complications, and prognosis), other available treatment options, and information about over-the-counter medications and self-help strategies.

Exercise: tailored for individual patient needs and lifestyle; moderate-intensity exercise, 30 min or more 3-4 times a week and continued indefinitely.

Physical modalities (heat, cold, and massage)

Cold for acute injuries in first 48 hours, to decrease bleeding or hematoma formation, edema, and chronic back pain. Heat works well for relief of muscle aches and abdominal cramping.


Non-drug treatment

Physical or occupational therapy; should be

conducted by a trained therapist

Chiropractic: Effective for acute back pain.

Potential spinal cord or nerve root

impingement should be ruled out before any

spinal manipulation

Acupuncture: Performed by qualified

acupuncturist. Effects may be short lived

and require repetitive treatments18.10.13 Pain-Elderly 29

Non-drug treatments

Relaxation: repetitive focus on sound, sensation, muscle

tension, inattention towards intrusive thoughts. Requires

individual acceptance and substantial training.

Meditation: Guided or self-directed technique for calming the

mind, allows thoughts, emotions and sensations to travel

through conscious awareness without judgment.

Progressive muscle relaxation: Individual tensing and relaxing

of certain muscle groups.

Hypnosis: effective analgesic, state of inner absorption and

focused attention. Reduces pain by distraction, altered pain

perception, increased pain threshold.Norelli L J et.al., : Behavioral approaches to pain management in the elderly, 24(2), Clinics in Geriatric Medicine, 2008.


Consequences of untreated pain

Impaired function: Pain can lead to decreased activity and ambulation leading to de-conditioning, gait disturbances and injuries from falls.

Sleep deprivation: decrease pain thresholds, limit the amount of daytime energy, increased risk of depression and mood disturbances.

Increases financial and care giving burdens placed on families and friends by increased utilization of health care services.

Diminished quality of life by isolating individuals from important social stimulation, amplifying the functional and emotional losses already experienced from undertreated pain.

Jakobsson, U. et.al., Old people in pain: A comparative study. Journal of Pain and Symptom Management, 26, 625-636,2003.Weiner, D.K., et.al., Pain in nursing home residents; management strategies. Drugs and Aging, 18(1), 13-19,2001.


Epidemiology of LBP

Among Older Adults

LBP in Older Adults

• Little research has been done in the area of

LBP among the older population (>65yrs).

• Reasons for lack of research interest in

older adults with LBP?

– Younger, working population

– Less serious than other conditions/diseases

– Societal attitudes


Epidemiology

• Prevalence of LBP is uncertain in 65yo+

– 6.8% to 49%

• Factors influencing prevalence reports

– cognitive impairment, decreased pain

perception, co-morbidities, resignation to

perceived effects of aging, depression


What do we know so far?

• Back Pain is associated with impaired function

(ADL’s and mobility)– SOF (women)

– Iowa 65+ Rural Health Study

– WHAS (women)

– Framingham

– Health ABC

*primarily measure self-reported function

• Very little research done in the areas of underlying

mechanisms or interventions in this age group


1.67

1.77

1.87

1.97

2.07

2.17

2.27

Year 1 Year 4

No/Mild Back Pain Mod/Extreme Back Pain

Back Pain and Function

Hicks et al, J Gerontol Med Sci, Nov 200518.10.13 Pain-Elderly 36

https://209.213.209.137/ucsf_cc/version1.5/habc/welcome.asp?studyname=HABC&servername=Medusa&databasename=HABCEdits


• Population-based survey study

• 522 men (32%) and women

• Aged 60 and above

• Independently living resident in one of four CCRCs

in MD and Northern VA

Retirement Community Back Pain Study


30

35

40

45

50

55

60

65

70

PCS MCS

No pain LBP only LBP + leg pain

PCS and MCS Subscale Scores

by LBP status

Good Health

Poor Health

Norm

P<.0001 P<.0001


LBP Status and Functional Limitations

Odds Ratio (95% CI)

Any LBP vs. No pain LBP+LP vs. No pain

Difficulty with…

Lifting or carrying

grocery bags

1.16 (0.93, 1.46) 4.60 (2.51, 8.43)

Climbing a flight

of stairs

2.03 (1.29, 3.17) 4.69 (2.31, 9.51)

Bending, kneeling

or stooping

1.68 (1.10, 2.57) 3.68 (1.82, 7.42)

Adjusted for age, sex, race, marital status, education, BMI and

chronic conditions18.10.13 Pain-Elderly 39


Odds Ratio (95% CI)


Difficulty with…

Walking several

blocks

1.18 (0.95, 1.46) 3.97 (2.19, 7.20)

Walking one block 1.00 (0.80, 1.25) 3.79 (2.05, 6.99)

Bathing and

dressing

1.08 (0.83, 1.39) 3.53 (1.54, 8.09)




Odds Ratio (95% CI)


Fallen in past year 1.10 (0.90, 1.34) 2.05 (1.11, 3.78)

Assistive device

for walking

1.02 (0.82, 1.27) 2.81 (1.45, 5.46)

Fair/poor self-

rated health

1.09 (0.87, 1.38) 2.64 (1.34, 5.31)

Social interference

due to physical

problems

1.08 (0.80, 1.46) 8.94 (2.73, 29.26)



• Less than half (45.2%) with LBP sought care

– LBP only: 30% sought care

– LBP + leg pain: 65% sought care

• All sought care with a physician, but no other

healthcare practitioners (i.e. PT, DC, CMT)

• Only 37.7% took prescription meds for LBP

Care-seeking and LBP


• Two mainstays in conservative management of LBP

are active rehabilitation and medication use

– Interestingly, no one received PT services and <40% were

prescribed medicine

• Why do so few older adults seek care?

• The combination of high prevalence and low care-

seeking suggests that clinicians who see older adults

should routinely:

– Ask targeted questions about LBP and leg pain

– Make appropriate referrals prn to prevent decline

Summary


Epidemiology

• Depression and Back Pain in the Elderly– Depressive symptoms are common in older adults

– Depressive symptoms and LBP are strongly associated in

cross-sectional studies

– Chronic pain can increase risk for depressive symptoms

– Depressive symptoms are a strong, independent risk factor

for onset of disabling back pain 1 year later (Reid, 2003)

– Disabling LBP increases odds of depressive symptoms 2

years later (Meyer, 2007)

– Relationship may be bi-directional


Classification and Staging

of Older Patients with LBP

First-Level Classification

Physical Therapy Only Consultation Referral

Stage 1

Stage 2

Stage 3

Inflammatory Process

(Medical)

Psychological

Medical

Psychological

Surgical



Serious Pathology

• Sleep disturbances

• Bowel/Bladder Dysfunction

• Unexplained Weight Loss

• Recent Episodes of Fever Related to LBP

• Trauma



Serious Pathology

• Abdominal Aortic Aneurysm (AAA)

– Ballooning of the aorta

• Risk factors- HTN and atherosclerosis

• Most often seen in older, Caucasian men

• Medical emergency when rupture occurs




Abdominal Aortic Aneurysm (AAA)

– Symptoms

• Back pain—severe, sudden, persistent

• Pulsating sensation in abdomen

• Pain in abdomen

• Nausea and vomiting

• Light-headedness and fainting with upright posture

– Signs

• Bruit on auscultation “Whooshing sound”

• Pulsatile mass sensitive to palpation around umbilicus

• Rapid Pulse18.10.13 Pain-Elderly 50

Second-Level Classification


Third-Level Classification

• Immobilization

• Mobilization

– Sacroiliac

Mobilization

– Lumbar

Mobilization

• Specific Exercise

– Extension Syndrome

– Flexion Syndrome*

– Lateral Shift

(able to centralize)

• Traction


Differential Diagnosis:

LBP vs. Hip Pain

LBP vs. Hip Pain

• Source = Lumbar spine

– Provocation and amelioration of symptoms

with spinal movement

• Source = Hip

– Hip Osteoarthritis (OA)

– Hip fracture

– Trochanteric bursitis

Ben-Galim et al. Hip-spine syndrome: the effect of total hip replacement surgery

on low back pain in severe osteoarthritis of the hip. Spine 200718.10.13 Pain-Elderly 54

Hip OA(Altman et al, 1991)

Presence of all 5 findings

• Hip Pain

• Hip IR > 15 degrees

• Pain with Hip IR

• Morning Stiffness

< 60 minutes

• >50 years of age

Presence of all 3 findings

• Hip Pain

• Hip IR < 15 degrees

• Hip Flexion < 115

degrees

Undiagnosed hip OA is one of the leading causes of failed

back surgery syndrome18.10.13 Pain-Elderly 55

Management of the Patient

in Stage I

Stabilization/Immobilization

Category

Do we need to address the core

muscles to reduce pain and improve

function in older adults with LBP?

Kirkaldy-Willis Model of LBP

DysfunctionDegenerative changes begin

InstabilityAbnormal movement due to degenerative changes

StabilizationSevere degenerative changesDevelopment of osteophytesMotion limitations18.10.13 Pain-Elderly 58

Spinal Stabilizing System

The spinal stabilizing system consists of

three inter-related subsystems:

Neuromuscular

Control

Passive

Subsystem

Active

Subsystem


Active Subsystem:

Aging Factors• Decreased muscle strength and mass associated

with aging (Sarcopenia)

– May be due to a decrease in number of muscle fibers,

size of individual fibers or both

• Type II (fast-twitch) fiber atrophy associated

with aging

– Results in slower muscle contractile properties

– Can be reversed with training

• Decreased muscle attenuation (increased

intramuscular fat infiltration) is associated with

aging muscle 18.10.13 Pain-Elderly 60

• Longitudinal cohort study

• 3075 black (42%) and white, men (48%) and women

• Aged 70-79 years between 4/97 – 6/98

• Community-resident in Memphis or Pittsburgh

• Well-functioning- no reported difficulty walking ¼ mile, up 10 steps,

or performing basic ADL

- no need for a walking aid or proxy respondent

• Present analysis—Pittsburgh site only•1527 black (44%) and white, men (48%) and women

•CT scans of paraspinous muscles only done in Pittsburgh

Health, Aging and Body Composition Study




14

16

18

20

22

24

Baseline

No LBP Mild LBP Mod LBP Severe/Extreme LBP

Back Pain & Trunk Muscle Composition

Hicks et al, J Gerontol Med Sci, Jul 2005

p-value for trend <.0001




1.67

1.77

1.87

1.97

2.07

2.17

2.27

Year 1 Year 4

No/Mild Back Pain Mod/Extreme Back Pain

Back Pain and Function

Hicks et al, J Gerontol Med Sci, Nov 200518.10.13 Pain-Elderly 63



Variable Parameter

Estimate

Standard

Error

Partial

R2

Intercept 2.585 .590

Trunk Muscle Attenuation .006* .002 .123

Thigh Muscle Attenuation -.002 .003 .024

Back Pain Severity -.088* .029 .003

Covariates .369

Model R2=.519† Dependent Variable=Health ABC PPB


Muscle attenuation, HU, at Year 1Hea

lth

AB

C P

hysi

cal

Per

form

ance

Bat

tery

Yea

r 4

No/Mild Back Pain

Mod/Extreme Back Pain


Variable Parameter

Estimate

Standard

Error

Partial

R2

No/Mild Back Pain

Intercept 2.500 .667

Trunk Muscle Attenuation .005* .002 .087


Covariates .372

Model R2=.484‡ Dependent Variable=Health ABC PPB

Moderate/Extreme Back Pain

Intercept 2.312 1.240

Trunk Muscle Attenuation .006† .004 .178


Covariates .336

Model R2=.537‡ Dependent Variable=Health ABC PPB18.10.13 Pain-Elderly 66

Point

Estimate 95% CI

Trunk Muscle Attenuation

1st Quartile (Lowest Quality) 4.50 (1.55, 13.03)

2nd Quartile 3.10 (1.29, 7.46)

3rd Quartile 1.61 (.73, 3.58)

4th Quartile (Best Quality) 1.00 ------

Trunk Muscle Attenuation & Falls in

Elders with Significant LBP

Model was adjusted for age, sex, race, BMI, disease status, thigh muscle

composition, benzodiazepine use and year 1 functional performance score.

Hicks et al, Unpublished preliminary data18.10.13 Pain-Elderly 67



• Addressing trunk muscle composition/ core

muscle integrity may be an important, yet

overlooked, approach to manage symptoms,

maintain functional mobility and potentially

reduce balance impairments and falls in older

adults with a history of significant back pain

Conclusions


Mobilization Sub-Group:

Aging Factors

• Facet joint degeneration (OA) is associated with the

aging spine

• Dessication of the disc occurs with time

• Changes in the disc height also affect amount of

loading on the facet joints and can lead to

approximation of spinous processes

• Which position is more likely to irritate facet joints--

flexion or extension?

• What types of manipulation techniques to avoid?18.10.13 Pain-Elderly 69

Mobilization Sub-Group:

Aging Factors• Consider use of muscle energy techniques

• Must consider entire patient history before undertaking

manipulation or mobilization

• Any factors that would suggest manipulation/

mobilization as unsafe or questionable

– osteoporosis, infection, fracture, spondylolysis/listhesis, CA,

prolonged steroid use, severe degenerative changes

– If any doubt, find another way to achieve the goal of

increasing mobility


Specific Exercise:

Key Examination Findings

• Extension Principle

– symptoms centralize with lumbar extension

– symptoms peripheralize with lumbar flexion

• Treatment

– Extension exercises

– Avoid flexion activities (bracing)

• Not typically seen in older adult


Specific Exercise:

Key Examination Findings

• Flexion Syndrome

– symptoms centralize with lumbar flexion

– symptoms peripheralize with lumbar extension

• Treatment

– Flexion exercises

– Avoid extension activities (bracing)

• *Typically seen in older adult


Lumbar Spinal Stenosis (LSS):

Flexion Syndrome Sub-Group

• LSS = narrowing of the spinal canal, nerve

root canal, and/or intervertebral foramina

• Usually acquired due to degenerative

changes

– facet joint arthrosis, ligamentum flavum

thickening, posterior bulging of discs,

spondylolisthesis

• Leg pain reported in 90% of cases

• Neurologic changes in 50% of cases18.10.13 Pain-Elderly 73



• Extension results in narrowing of the

dimensions of the central and lateral spinal

canals

• Axial loading also narrows the canals




• Key Exam Findings

– Age > 65 (+LR=2.5)

– No pain when seated (+LR=6.6)

– Symptoms improved when seated (+LR=3.1)

– Improved walking tolerance with spinal flexion

(+LR=6.4)




Differential Diagnosis: Neurogenic vs.

Vascular Claudication

• Both conditions may present as cramping

pain, tightness and fatigue in LE’s during

walking and relieved by sitting

• Vascular claudication is typically secondary

to PAD




Differential Diagnosis: Neurogenic vs.

Vascular Claudication

• Bicycle Test (Dyck & Doyle, 1977)

– Neurogenic -- Pt would pedal further with

flexed spine than with extended spine

– Vascular --Pt would pedal equal distances

regardless of position of the spine

– Results were not sufficiently sensitive for this

test (Dong and Porter, 1989)18.10.13 Pain-Elderly 77



Differential Diagnosis: Neurogenic vs. Vascular Claudication

• Ankle Brachial Index

– Supine

– Typical systolic measurement from arm

– Systolic measurement from leg

• Cuff around ankle

• Dorsalis Pedis or Posterior Tibial Arteries

– <.90 indicates Peripheral Arterial Disease




Two-Staged Treadmill Test

• Pt walks on level surface (10 min or

fatigue) followed by incline surface (10 min

or fatique) with a 10 min rest break in

between

– Earlier onset of symptoms on level vs. incline

(+LR=4.1 for neurogenic claudication)

– Longer recovery time after level vs. incline

(+LR=2.6 for neurogenic claudication)18.10.13 Pain-Elderly 79



• Surgical intervention is common

– Fusion and Decompression Procedures

• Surgical rates are on the rise for LSS

• In 1994, nearly $1billion spent on LSS surgery

• 23% re-operation rate

• Increased complication rates when surgical

interventions used on older adults

• Non-surgical treatment has not been well-

explored yet.18.10.13 Pain-Elderly 80



• Comparison between 2 PT treatments for LSS (Whitman et al, Spine, 2006)

– Randomized to:

• Flexion, Sub-therapeutic ultrasound and Level walking

on treadmill

or

• Manual Therapy, Exercise and Body-Weight Supported

walking on treadmill


BWS Treadmill Ambulation

• De-weighted ambulation on a treadmill is also an option. (Fritz et al., Phys Ther, 1997)

• Shown to reduce compressive forces on the body. (Flynn et al., Phys Ther, 1997)

• Progression is made by decreasing the traction force.




Healthcare

Pain in elderly