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Pain Assessment in Older Adults

Introduction

Older adults often experience acute and chronic diseases associated with pain. Geriatric patients often take several medications to treat the symptom (Horgas, 2017). However, taking multiple pain management medications attributes to polypharmacy and may negatively affect the well-being of older patients (Horgas, 2017).

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Thus, it is crucial that clinicians make adequate treatment plans to ensure the best outcomes. In order to choose the best treatment plan, care providers need to assess pain carefully. The present paper overviews current methods for assessing pain in geriatric patients and describes the effects of pain functioning of older adults.

Pain Assessment Tools

There are several types of pain assessment tools for older adults. The preferable tools by older adults without impaired cognitive ability are the numeric rating scales (NRSs) (Resnick et al., 2019). This is a simple method, where the care provider asks to evaluate the intensity of pain on a scale from zero to five, ten, or twenty, where zero stands for no pain (Horgas, 2017). However, many older adults report to experience difficulty with using this self-reported tool, as it requires abstract thinking.

Verbal descriptor scales (VDSs) can be used instead of NRSs, as they do not require abstract thinking. VDSs substitute numbers with phrases, such as ‘no pain’, ‘mild pain’, ‘severe pain’ (Horgas, 2017). This method can be completed by the majority of older patients, even with cognitive impairment. There is also significant evidence that pictorial pain scales (PPSs) can be used to assess pain in older adults with no, low, or moderate cognitive impairment (Horgas, 2017). This test uses pictures of people in pain, and older adults are offered to select the picture that most suits the situation.

While the tools mentioned above can help with assessing pain in patients with cognitive impairment, they do not produce reliable results, especially for patients with significant cognitive impairment. According to Kappesser et al. (2020), care providers should use either Faces of Pain Scale-Revised (FPS-R) or the PAIC (pain in impaired cognition) tool. PAIC is a collection of tools that uses facial expressions, vocalization, and movement to assess pain (Kappesser et al., 2020).

This is done as self-reported tools are often inapplicable to patients with severe cognition problems. However, PAIC and FPS-R may be inappropriate for geriatric patients without cognitive problems, as their accuracy is lower than that of self-reported tools. Moreover, it is usually better to use the item preferred by patients.

Beers Criteria Application

When treating pain in older adults, it is crucial to apply Beers Criteria that considers how age-related changes affect the pharmacokinetics and pharmacodynamics of medicine. According to Höchel (2019), geriatric patients may experience changes in absorption, distribution, metabolism, and excretion. When speaking about treatment of chronic pain, recent changes in Beers criteria promote a cautious use of opioids for treating chronic pain. According to American Academy of Family Physicians (AAFP, 2020), tramadol may cause hyponatremia in older adults; thus, its use should be limited.

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Additionally, AAFP (2020) recommends to avoid prescribing opioids with benzodiazepines or gabapentinoids due to an increased risk of a severe respiratory depression. American Geriatrics Society (AGS, 2019) recommends to prescribe opioids in caution due to an increased risk of death from opioid overdose. The problem is that geriatric patients tend to have difficulty with remembering what medications they have already taken (AGS, 2019). In general, care providers should take into consideration the effects of polypharmacy on geriatric patients.

Care providers may experience significant issues while assessing patients with age-related sensory changes, such as eyesight, hearing, and diminished peripheral touch or pain sensations. Clinicians need to remember that there is no one-size-fits-all solution for all types of sensory deficits. Thus, an individual approach is required to select the most appropriate tool. Before selecting a tool, it is crucial that care providers make sure that the patient can use it (Horgas, 2017).

The eyesight problems may make patients unable to take self-administration tests and help of care providers may be required. If a patient has hearing problems, care providers should promote the use of written screening tools to facilitate the process. Finally, when considering sensory changes, patients may have decreased ability to feel pain, which may complicate the screening process. Clinicians should remember that assistive devices can help geriatric patients use tools they would not be able to use otherwise. However, care providers need to make sure that the devices are intact, as poor working conditions of the devices can negatively impact the pain assessment process (Horgas, 2017).

Neuropathic Pain

Pain caused by diseases affecting the somatosensory nervous system is called neuropathic pain. It can be associated with painful sensations from usually non-painful stimuli (Morgan & Anghelescu, 2017). Such pain may be present in pediatric, adult, and geriatric patients; however, it is more frequent in older adults (Morgan & Anghelescu, 2017). There are several tools that can help to assess neuropathic pain, including ID Pain, Neuropathic Pain Scale (NPS), and Neuropathic Pain Symptom Inventory (NPSI).

ID Pain is a self-administered test that consists of six yes-no questions. While this test seems to be the easiest for geriatric patients to administer, it has the lowest sensitivity (69%) among the alternatives (Morgan & Anghelescu, 2017). However, clinicians should consider using this tool for patients with cognitive limitations. NPS was specifically designed for assessing neuropathic pain.

According to Morgan and Anghelescu (2017), “this questionnaire is easily administered, widely available, and well suited for examining the ability of specific treatments to improve neurotic pain” (p. 849). NPSI is also a highly reliable tool that can be used to assess treatment efficacy (Morgan & Anghelescu, 2017). There are at least six other tools that can be used to assess neuropathic pain; thus, care providers should familiarize themselves with all of them to select the most appropriate for every patient.

When treating neurotic pain, it is recommended that care providers carefully assess the patients and polypharmacy in older adults (Pickering et al., 2016). Neurotic pain treatment should start with low doses of one medication and slowly increasing the dose if needed (Pickering et al., 2016). Monotherapy is preferred to decrease the effects of polypharmacy (Pickering et al., 2016).

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First-line treatment of neurotic pain “includes antidepressants, anti-epileptics, lidocaine 5 %, and capsaicin plasters” (Pickering et al., 2016, pp. 580-581). Second-line treatment is tramadol, while the third-line treatment is strong opioids, such as morphine (Pickering et al., 2016).

Pain Assessment and Functioning

Pain can have a negative impact on the functioning of older adults. Chronic pain often leads to decreased appetite, irritation, anger, and a decreasing ability to perform every-day actions (Horgas, 2017). Additionally, chronic pain may cause sleep disturbance, decreased physical activity, and impaired ability to concentrate (Horgas, 2017). Comprehensive and frequent pain assessment can help care providers to select the most effective strategy for controlling pain (Kappesser et al., 2020). Therefore, pain assessment can improve the functioning of geriatric patients.

References

American Academy of Family Physicians. (2020). Beers criteria for inappropriate medication use in older patients: An update from the AGS. American Family Physician, 101(1), 56-57.

American Geriatrics Society. (2019). Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. QIO Program.

Höchel, J. (2019). Does everything get slower with age? Pharmacokinetics in the elderly. Drug Research, 69(S 01), S7-S8.

Horgas, A. L. (2017). Pain assessment in older adults. Nursing Clinics, 52(3), 375-385.

Kappesser, J., Voit, S., Lautenbacher, S., & Hermann, C. (2020). Pain assessment for cognitively impaired older adults: Do items of available observer tools reflect pain‐specific responses? European Journal of Pain, 24(4), 851-862.

Morgan, K. J., & Anghelescu, D. L. (2017). A review of adult and pediatric neuropathic pain assessment tools. The Clinical Journal of Pain, 33(9), 844-852.

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Pickering, G., Marcoux, M., Chapiro, S., David, L., Rat, P., Michel, M.,… & Wary, B. (2016). An algorithm for neuropathic pain management in older people. Drugs & aging, 33(8), 575-583.

Resnick, B., Boltz, M., Galik, E., Holmes, S., Vigne, E., Fix, S., & Zhu, S. (2019). Pain assessment, management, and impact among older adults in assisted living. Pain Management Nursing, 20(3), 192-197.

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