Older adults frequently experience pain, which can significantly impact their quality of life and functional abilities. This document provides comprehensive Guidance for healthcare professionals across all care settings who are managing pain in older people. It is based on a thorough review of published research to outline best practices and pinpoint areas where further research is needed. Please note that the assessment of pain in older people is detailed in a separate guidance document.
Understanding Pain Prevalence in Older Populations
Determining the definitive prevalence of pain in older adults is challenging due to substantial variations in study populations, methodologies, and definitions. Current literature presents inconsistencies regarding whether pain prevalence increases or decreases with age, and the influence of gender on this. However, evidence suggests a higher prevalence of pain in residential care settings. The most commonly reported pain locations are the back, leg/knee or hip, and other joints, mirroring trends observed in the working-age population. Crucially, like younger individuals, the attitudes and beliefs of older people profoundly shape their pain experience, with stoicism being a notable characteristic in this age group.
Pharmacological Guidance for Pain Relief
Research indicates that paracetamol should be the first-line treatment for managing both acute and persistent pain in older adults, particularly musculoskeletal pain. This recommendation stems from paracetamol’s proven efficacy and favorable safety profile. Contraindications are minimal, and cautions are relative, but adhering to the maximum daily dose (4 g/24 hours) is essential.
Non-selective Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) should be used cautiously in older people, reserved for cases where safer alternatives have not provided adequate pain relief. When prescribing NSAIDs, the lowest effective dose for the shortest possible duration is advised. In older adults, co-prescription of an NSAID or a cyclooxygenase-2 (COX-2) selective inhibitor with a proton pump inhibitor (PPI) is recommended, prioritizing the most cost-effective option. Regular monitoring for gastrointestinal, renal, and cardiovascular side effects, as well as drug-drug and drug-disease interactions, is crucial for all older individuals taking NSAIDs.
Opioid therapy can be considered for older patients experiencing moderate to severe pain, especially when pain impairs function or diminishes quality of life. However, opioid use must be individualized and closely monitored. Anticipating and proactively managing opioid side effects, such as nausea and vomiting, is important. Prescribing appropriate laxative therapy, like a combination of a stool softener and a stimulant laxative, is recommended for all older adults on opioid therapy throughout the duration of treatment.
Tricyclic antidepressants and anti-epileptic drugs have demonstrated effectiveness in managing various types of neuropathic pain. Nevertheless, their use in older populations is limited by tolerability issues and potential adverse effects.
Intra-articular corticosteroid injections are effective for short-term pain relief in knee osteoarthritis, with a low risk of complications or joint damage. Intra-articular hyaluronic acid presents another effective option, free from systemic adverse effects, and is suitable for patients intolerant to systemic therapies. While intra-articular hyaluronic acid may have a slower onset of action compared to steroids, its effects appear to be longer-lasting.
Current evidence regarding epidural steroid injections for sciatica management is inconclusive, preventing firm recommendations until more extensive studies are available. However, limited evidence supports the use of epidural injections for spinal stenosis.
Non-Pharmacological Guidance and Supportive Measures
Literature highlights the widespread use of assistive devices, with ownership increasing with age. These devices enable older people with chronic pain to maintain independence within the community. It’s important to note that while assistive devices aid independence, they may not directly reduce pain and can even exacerbate pain if used incorrectly.
Increased physical activity through exercise should be strongly considered as part of pain management. Exercise programs should incorporate strengthening, flexibility, endurance, and balance exercises, alongside patient education. Patient preferences should be a significant factor in designing exercise regimens.
Complementary therapies such as acupuncture, Transcutaneous Electrical Nerve Stimulation (TENS), and massage have shown some efficacy in older populations. These approaches can positively influence both pain and anxiety levels and warrant further exploration.
Certain psychological approaches, including guided imagery, biofeedback training, and relaxation techniques, have proven beneficial for older adults. Cognitive Behavioral Therapy (CBT) also shows promise in nursing home populations, although these methods require trained professionals and dedicated time.
Areas for Future Research and Guidance Development
Numerous areas require further research to enhance pain management guidance for older adults. Pharmacological management strategies are often tested in younger populations and subsequently applied to older adults, highlighting a need for age-specific research. Prevalence studies need to adopt consistent age ranges, diagnoses, and terminology to improve comparability and accuracy. Furthermore, more comprehensive evaluation of non-pharmacological approaches is crucial to broaden the evidence base for holistic pain management in older people.
