Seniors and Pain
Pain in Older Adults
By: Debra K. Weiner, MD
Pain is a common part of the lives of many older adults. Researchers estimate that as many as one half of older adults who live independently and three-fourths of those who live in nursing homes suffer from persistent pain, that is, pain that does not go away.1 Most often, this type of pain is caused by arthritis, nerve damage, and muscular problems.
There are a wide variety of treatment options available to help older adults with persistent pain. Unfortunately, health care providers often do not receive the proper education regarding how to help older adults who suffer with persistent pain. There are a lot of misunderstandings and myths about pain in older people. The purpose of this article is to dispel some of these myths and give you some basic information to take to your primary care provider so that you can get the kind of help that you need.
Myth: Persistent pain is a normal part of aging.
Fact: While persistent pain certainly becomes more common as people age, it is not normal to hurt. The presence of pain means that there is something causing it. Sometimes the cause may be relatively simple such as muscular strain, but sometimes it is more complicated, and an entire team of specialists such as pain doctors, physical therapists, and psychologists may need to treat you to help you to get better. Pain should never be accepted as normal.
Myth: Tests usually are needed to determine the cause of pain.
Fact: Often, health care providers order tests such as x-rays, MRIs and blood tests to evaluate pain problems. Most of the time, however, these sorts of tests are not necessary. Health care providers usually can determine and prescribe the most appropriate treatment by talking with and examining the patient. If your health care provider orders special tests, ask him or her how the results of the tests will change the treatment he or she prescribes. X-rays and MRIs often are ordered for older adults with low back pain. Many research studies, however, have shown that these tests are not helpful because many of the same "abnormalities" seen in patients with low back pain also are seen in people who are pain-free.2 3 X-rays and MRIs often are more useful for determining what is not causing a person's pain.
Myth: Most persistent pain in older adults is caused by arthritis, so the most sensible treatment is arthritis medications.
Fact: Arthritis is very common in older adults, but most people have evidence of arthritis on x-rays but do not have pain. Muscular strain and irritation – known as myofascial pain – also is extremely common in patients with a variety of persistent pain conditions, but often is not recognized by primary health care providers as a cause of pain. Diagnosing myofascial pain, which can be done simply with a physical examination, is important because medications often are not the most effective treatment for this condition. Muscle-related pain is treated most effectively with various types of modalities administered by a physical therapist such as heat, ice, gentle stretching, myofascial release techniques, or electrical stimulation. Shots in the tight muscles known as trigger point injections also might be helpful. These kinds of treatments have much fewer side effects and less risk than most pain medications.
Myth: Older adults should not take opioids because of the potential for addiction.
Fact: Opioids, commonly known as narcotics, are strong pain medications that may be necessary to treat severe pain. When used carefully, these medications, including morphine, hydrocodone, oxycodone, fentanyl patches, and methadone, can do a very good job of controlling pain without serious side effects. As with any medication, patients who take these medications should be carefully monitored by their doctors. Patients frequently express concern when their health care provider suggests taking these medications because they fear addiction, but this problem is quite uncommon. The word "addiction" means that patients develop a psychological craving for medication even when they do not have a physical need for it. Most older adults with persistent pain conditions have a real need for pain medication, so the likelihood of becoming addicted is less than 1 in 200.4
Myth: Persistent pain in older adults is not likely to get better, so these patients need to learn to live with it.
Fact: Actually, many effective treatments are available for most kinds of pain that occur in older patients. Medications are only one small part of pain treatment. The main goal of pain treatment is to maximize the patient's ability to be active and engaged in life. Studies have shown that even though persistent pain usually cannot be completely eliminated (that is, even with excellent treatment, pain that is persistent is not likely to go away), patients can still enjoy significant improvements in their function and quality of life.5 In other words, even if pain treatment results in only a modest reduction in pain, it is still likely that function and quality of life can improve significantly.
Myth: Activity is harmful in the older adult with pain.
Fact: Maintaining an active lifestyle is actually one of the major goals of pain treatment. Patients with some types of pain, such as that associated with nerve damage (known as neuropathy), actually experience less pain when they are active. Those with arthritis and muscular pain also benefit from activity. Often patients ask, "How much activity is too much?" Typically the most accurate answer to this question lies with the patient's own individual experience. Activity that is followed by significant worsening of pain should be treated with rest the following day, and probably less intense activity on a routine basis. Before engaging in vigorous physical activity like running, biking, or fast-paced walking, patients should get their doctor's approval.
Myth: Older adults with pain and depression will experience improvement in their mood when their pain has improved.
Fact: Not necessarily. People with persistent pain often experience feelings of sadness, irritability, and poor sleep. Sometimes these feelings improve when pain improves. If these feelings are strong, however, it is important that they be treated with antidepressant medications. If they are ignored, it may be more difficult to treat the pain. In other words, pain and depression can become part of a vicious cycle, and unless all parts of the cycle are addressed, neither pain nor depression can be treated effectively.
Myth: As long as pain is not caused by cancer, it is not harmful.
Fact: Persistent pain, no matter what the underlying cause, can have a wide range of effects on patients. Some of the more common include difficulty performing activities of daily living like bathing, dressing, and cooking; depression and anxiety; impaired appetite; difficulty concentrating; and trouble sleeping. Patients with persistent pain also tend to make visits to emergency rooms and doctors' offices more often than other people. So, persistent pain is not just an inconvenience – it deserves to be treated aggressively and effectively.
Myth: If physical therapy previously caused worsening of pain, it should not be prescribed in the future.
Fact: Nothing could be further from the truth. There are a wide variety of physical therapy techniques, and a wide range of physical therapists with different training and clinical experience. The best therapists from whom to seek treatment for persistent pain conditions are those who have a lot of experience in treating these conditions. If physical therapy is administered too aggressively or in not quite the proper way, for example, patients may feel worse instead of better. This is particularly true for certain types of muscular conditions and back problems. If you have had physical therapy in the past and it was either not helpful or made you worse, do not take this as an indication that physical therapy cannot help you.
Myth: If certain medications were tried before and didn't help, there is no point in prescribing them again.
Fact: This is not necessarily true. Often, medications are prescribed incorrectly. That is, the doses previously used may not have been high enough. Or, side effects may have resulted if the dose was increased too rapidly. The decision about whether a medication should be tried again depends on the specific set of circumstances of each patient, but as with other aspects of pain management described above, it is important to remain open-minded about the possibility of a positive outcome.
Debra K. Weiner, M.D., is associate professor of medicine, psychiatry and anesthesiology in the division of geriatric medicine at the University of Pittsburgh School of Medicine and is Director of the Older Adult Pain Management Program at the University of Pittsburgh Pain Medicine Program. Dr. Weiner is the chief editor of Persistent Pain in Older Adults: An Interdisciplinary Guide for Treatment and has written numerous journal articles on the subject. She is board certified in internal medicine, rheumatology, and geriatric medicine and is a licensed acupuncturist.
What Can Be Done to Help Older Adults With Persistent Pain?
There are a wide variety of treatment options available to help older adults with persistent pain. Unfortunately, health care providers often do not receive the proper education regarding how to help older adults who suffer with persistent pain. There are a lot of misunderstandings and myths about pain in older people. The purpose of this article is to dispel some of these myths and give you some basic information to take to your primary care provider so that you can get the kind of help that you need.
Myth: Persistent pain is a normal part of aging.
Fact: While persistent pain certainly becomes more common as people age, it is not normal to hurt. The presence of pain means that there is something causing it. Sometimes the cause may be relatively simple such as muscular strain, but sometimes it is more complicated, and an entire team of specialists such as pain doctors, physical therapists, and psychologists may need to treat you to help you to get better. Pain should never be accepted as normal.
Myth: Tests usually are needed to determine the cause of pain.
Fact: Often, health care providers order tests such as x-rays, MRIs and blood tests to evaluate pain problems. Most of the time, however, these sorts of tests are not necessary. Health care providers usually can determine and prescribe the most appropriate treatment by talking with and examining the patient. If your health care provider orders special tests, ask him or her how the results of the tests will change the treatment he or she prescribes. X-rays and MRIs often are ordered for older adults with low back pain. Many research studies, however, have shown that these tests are not helpful because many of the same "abnormalities" seen in patients with low back pain also are seen in people who are pain-free.2 3 X-rays and MRIs often are more useful for determining what is not causing a person's pain.
Myth: Most persistent pain in older adults is caused by arthritis, so the most sensible treatment is arthritis medications.
Fact: Arthritis is very common in older adults, but most people have evidence of arthritis on x-rays but do not have pain. Muscular strain and irritation – known as myofascial pain – also is extremely common in patients with a variety of persistent pain conditions, but often is not recognized by primary health care providers as a cause of pain. Diagnosing myofascial pain, which can be done simply with a physical examination, is important because medications often are not the most effective treatment for this condition. Muscle-related pain is treated most effectively with various types of modalities administered by a physical therapist such as heat, ice, gentle stretching, myofascial release techniques, or electrical stimulation. Shots in the tight muscles known as trigger point injections also might be helpful. These kinds of treatments have much fewer side effects and less risk than most pain medications.
Myth: Older adults should not take opioids because of the potential for addiction.
Fact: Opioids, commonly known as narcotics, are strong pain medications that may be necessary to treat severe pain. When used carefully, these medications, including morphine, hydrocodone, oxycodone, fentanyl patches, and methadone, can do a very good job of controlling pain without serious side effects. As with any medication, patients who take these medications should be carefully monitored by their doctors. Patients frequently express concern when their health care provider suggests taking these medications because they fear addiction, but this problem is quite uncommon. The word "addiction" means that patients develop a psychological craving for medication even when they do not have a physical need for it. Most older adults with persistent pain conditions have a real need for pain medication, so the likelihood of becoming addicted is less than 1 in 200.4
Myth: Persistent pain in older adults is not likely to get better, so these patients need to learn to live with it.
Fact: Actually, many effective treatments are available for most kinds of pain that occur in older patients. Medications are only one small part of pain treatment. The main goal of pain treatment is to maximize the patient's ability to be active and engaged in life. Studies have shown that even though persistent pain usually cannot be completely eliminated (that is, even with excellent treatment, pain that is persistent is not likely to go away), patients can still enjoy significant improvements in their function and quality of life.5 In other words, even if pain treatment results in only a modest reduction in pain, it is still likely that function and quality of life can improve significantly.
Myth: Activity is harmful in the older adult with pain.
Fact: Maintaining an active lifestyle is actually one of the major goals of pain treatment. Patients with some types of pain, such as that associated with nerve damage (known as neuropathy), actually experience less pain when they are active. Those with arthritis and muscular pain also benefit from activity. Often patients ask, "How much activity is too much?" Typically the most accurate answer to this question lies with the patient's own individual experience. Activity that is followed by significant worsening of pain should be treated with rest the following day, and probably less intense activity on a routine basis. Before engaging in vigorous physical activity like running, biking, or fast-paced walking, patients should get their doctor's approval.
Myth: Older adults with pain and depression will experience improvement in their mood when their pain has improved.
Fact: Not necessarily. People with persistent pain often experience feelings of sadness, irritability, and poor sleep. Sometimes these feelings improve when pain improves. If these feelings are strong, however, it is important that they be treated with antidepressant medications. If they are ignored, it may be more difficult to treat the pain. In other words, pain and depression can become part of a vicious cycle, and unless all parts of the cycle are addressed, neither pain nor depression can be treated effectively.
Myth: As long as pain is not caused by cancer, it is not harmful.
Fact: Persistent pain, no matter what the underlying cause, can have a wide range of effects on patients. Some of the more common include difficulty performing activities of daily living like bathing, dressing, and cooking; depression and anxiety; impaired appetite; difficulty concentrating; and trouble sleeping. Patients with persistent pain also tend to make visits to emergency rooms and doctors' offices more often than other people. So, persistent pain is not just an inconvenience – it deserves to be treated aggressively and effectively.
Myth: If physical therapy previously caused worsening of pain, it should not be prescribed in the future.
Fact: Nothing could be further from the truth. There are a wide variety of physical therapy techniques, and a wide range of physical therapists with different training and clinical experience. The best therapists from whom to seek treatment for persistent pain conditions are those who have a lot of experience in treating these conditions. If physical therapy is administered too aggressively or in not quite the proper way, for example, patients may feel worse instead of better. This is particularly true for certain types of muscular conditions and back problems. If you have had physical therapy in the past and it was either not helpful or made you worse, do not take this as an indication that physical therapy cannot help you.
Myth: If certain medications were tried before and didn't help, there is no point in prescribing them again.
Fact: This is not necessarily true. Often, medications are prescribed incorrectly. That is, the doses previously used may not have been high enough. Or, side effects may have resulted if the dose was increased too rapidly. The decision about whether a medication should be tried again depends on the specific set of circumstances of each patient, but as with other aspects of pain management described above, it is important to remain open-minded about the possibility of a positive outcome.
Debra K. Weiner, M.D., is associate professor of medicine, psychiatry and anesthesiology in the division of geriatric medicine at the University of Pittsburgh School of Medicine and is Director of the Older Adult Pain Management Program at the University of Pittsburgh Pain Medicine Program. Dr. Weiner is the chief editor of Persistent Pain in Older Adults: An Interdisciplinary Guide for Treatment and has written numerous journal articles on the subject. She is board certified in internal medicine, rheumatology, and geriatric medicine and is a licensed acupuncturist.
References
- Farrell, M. J.; Gibson, S. J.; Helme, R. D. Chronic nonmalignant pain in older people. Pain in the Elderly. Seattle: IASP Press; 1996. pp. 81-9.
- Weiner DK, Distell B, Studenski S, Martinez S, Lomasney L, Bongiorni D. Does radiographic oseoarthritis correlate with flexibility of the lumbar spine? Journal of the American Geriatrics Society 1994;42:257-63.
- Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects - a prospective investigation. J Bone Joint Surg Am 1990;72(3):403-8.
- Porter J, Jick H. Addiction rare in patients treated with narcotics (letter). New Engl J Med 1980;302:123.
- Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 1992;49:221-30.