Does it hurt to grow old? The answer is an emphatic “No.” But what does hurt the elderly under our care is lack of appropriate assessment and treatment of their myriad health conditions because “they didn’t ask for pain medication.”

Caring for the elderly, whether in a private home or long-term care environment, presents challenges on several levels related to successfully managing their pain.

There may be multiple conditions afflicting the elderly patient and just as many reasons why the patient does not complain of pain. Some examples are:

• trying to be stoic for the family’s sake: “Why complain, it doesn’t help anyone by being miserable?”
• saying that nothing stops the pain all the time; I’m used to it.
• fearing looking weak.
• stating “I don’t want to be doped up most of the time.”
• having communication barriers.
• having cultural barriers due to heritage.
• being affected by cognitive barriers if the elderly person in question has dementia, for the dementia patient may not realize that what she is experiencing is pain.
• believing that pain is inevitable in aging.
• having fears of becoming addicted to pain medication

Caregivers face several potential barriers to successful management of pain in elderly loved ones and clients. The caregiver:

• may not be adequately familiar with the client’s condition.
• may be reluctant to use opioids fearing addiction.
• may lack the knowledge of alternative and non-medication treatment regimens or the care team may not give adequate priority to pain management.
• may not recognize the symptoms being displayed as responding to the pain stimulus.

What is pain? Officially, it is an unpleasant sensory and emotional experience associated with actual or potential tissue damage (1). Yet, because of its complexity, one cannot easily create a definition to satisfy or describe the sensation adequately for all situations.

Regardless of the situation, pain is whatever the person experiencing it says it is. Many caregivers emphasize its importance by calling it the fifth vital sign.

Pain may be acute or chronic. Acute pain usually has an identifiable source, an injury from trauma or surgery and is not long lasting. The goal is pain relief with rapid onset analgesics, with availability of suitable medication for breakthrough pain.

Chronic pain is caused by one or more conditions with a longer duration, lasting six months or longer. The goal here is to achieve pain relief and maintain pain control. With chronic pain, treatment is given regularly in anticipation of pain to preserve maximum function and quality of life at the highest level.

Chronic pain can be treated with opioid and/or non-opioid drugs and should be treated around the clock.

Alternative treatments such as guided imagery, pleasure foods and nutritional protocols, relaxation techniques, aroma therapy, massage, hypnosis, heat/cold packs, and immobilization have been successfully used for break-through pain.

Mild pain is treated with Tylenol or Tylenol with Codeine. The use of Darvocet is no longer recommended for elderly people because it takes so long to go through the system; there is risk of higher than therapeutic level in the blood.

Moderate pain is treated with Percodan, Percocet, Lortab, Vicodin, and Oxycontin.

Severe pain is treated with Morphine, Dilaudid, Fentanyl and Methadone. Severe chronic pain is managed by nerve severing, implanting pain pumps, and pain infusions.

The rule of prescribing medications for the elderly is “start low, go slow”. This means start with the mild drugs and slowly increase the dose based on the effectiveness of the pain medication.

How might elderly people show that they are in pain without using words? There are several key areas to assess for pain in dementia patients, non-verbal patients or patients who do not report pain: facial expressions, body position, body movements, moaning or other sounds, changes in level of alertness, mood, appetite, or sleep; and resistance to care.

The elderly may respond to the pain by yelling, moving about, or striking out at the closest person or object, a beloved or a stranger.

Nursing staff are expected to consider biological needs when assessing patients with dementia. They should check for hunger, thirst, toileting and sleep needs before giving pain medication.

State surveyors who annually evaluate nursing homes for care given, policies, staff performance and resident satisfaction align pain management with quality of life. They assign deficiencies in care against facilities who fail to assess, treat, monitor, and document its residents’ pain management regularly and thoroughly.

For more information on pain management, try the following organizations and websites: The International Association for the Study of Pain; American Geriatric Society Panel of Persistent Pain in Older Persons; John A. Hartford Centers of Geriatric Nursing Excellence; www.ngna.org; www.amda.com; and www.geriatricpain.org.

A closing thought from Albert Schweitzer, “We must all die. But if I can save him from days of torture, that is what I feel is my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.”
1. The International Association for the Study of Pain (2002).

Sarah Jean Fisher, MSN, RN-BC, BA is one of Med League’s long term care experts.

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