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Ann Agric Envi ron Med. 2013; Special Issue 1: 35–38
www.aaem.pl
ORIGINAL ARTICLE
The problem of pain in old age
Małgorzata Dziechciaż1,2, Luiza Balicka-Adamik3, Rafał Filip4
1 Non-Public Health Care Institution ‘DAR’, Jarosław, Poland
2 Health Care Institute, State School of Higher Vocational and Economic Education, Jarosław, Poland
3 Neurology Department, Medical Care Centre in Jarosław, Poland
4 Department of Clinical Endoscopy, Institute of Rural Health, Lublin, Poland
Dziechciaż M, Balicka-Adamik L, Filip R. The problem of pain in old age. Ann Agric Environ Med. 2013; Special Issue:35–38.
Abstract
The elderly are more susceptible to feeling pain than young people. Pain is described as a complex, subjective feeling
causing signicant limitation of physical, psychical and social functioning. In the literature, there are many classications
of pain. Considering the duration, pain may be divided into acute and chronic. Acute pain does not depend on age and
lasts less than three months whereas chronic pain is more frequent with the elderly and lasts more than three months. It
can be divided into nociceptive and neuropathic pain. Involutional changes progressing in the organism of an old person,
combined with numerous chronic diseases occurring in old age, cause approx. 85% of the elderly to suer from pain. Among
the diseases with concurring pain, the rst are diseases of the locomotor system and include: osteoporosis, osteoarthritis,
and rheumatoid arthritis. Moreover, pain is an intrinsic part of malignant cancer, neuralgia shingles, and diabetic n europathy.
Pain also conceals depression and the depression intensies the feeling of pain. Due to frequent cognitive disorders and
depression, the measurement of pain in the elderly is dicult, it thus requires vast experience. To assess the pain intensity,
subjective scales are used, e.g. verbal scale, score scale. To assess the qualitative and quantitative scales the following
questionnaires are used: McGill-Melzak Pain Questionnaire and the Pain Assessment Form. Signicant for pain assessment
with people diagnosed with dem entia are objective pain symptoms, nam ely: worsening appetite, gnashing teeth, grimaces.
Pain treatment should be multimodal and include usage of both pharmacological and non-pharmacological methods.
Pharmacology is the basis for pain treatment in people of old age, which should be used in the least invasive way, starting
with small dosages. The pain-relieving medicine of rst choice is paracetamol. In the pharmacological treatment of old
people there are also non-opioid pain relieving medicine, opioids and supportive medicine. Among non-pharmacological
treatments are rehabilitation and psychological therapy. In pain treatment, awareness among the elderly, their families
and carers, and medical sta that the pain is not an attribute of old age; thus, it can be correctly diagnosed and treated.
Key words
pain, people in old age, pain treatment in the elderly
INTRODUCTION
Old age predisposes the occurrence of chronic and wasting
diseases with one dominant symptom being pain [1]. Pain,
in accordance with the denition by the International
Association for the Study of Pain, is described as an
‘unpleasant sensory and emotional experience associated
with actual or potentia l tissue damage, or described in terms
of such damage’ [2, 3, 4]. Pain is a complex, subjective feeling
which can signicantly limit psychical and physical activ ity,
may lead to anxiety and fear for one’s own life, and may
prevent reception of any other sensations [3]. e sensation
of pain is caused by sensory stimulations and are modied
by memory, expectations and emotions [4]. ere are many
classications of pain, namely:
•
physical – informing on tissue damage, occurring as
stubbing, burning or tearing stimuli;
• emotional – indicating emotional disorders, indicated by
sadness, depression, guiltiness and fright;
• psychical – indicating psychical imbalance, indicated by
abashment or disorientation;
•
existential – emerging as a result of disintegration of
individual integrity, as a whole, indicated by a form of
despair, existential shame, guiltiness, severe fright. Diers
from the form of emotional pa in in depth and has a higher
level of threat to existence as a whole;
•
relational – emerging when human relationships are
disrupted; may be in the form of emotional, psychical
and existential, or a combination of thereof [3].
Considering the duration, pain may be divided into acute
and chronic.
•
Acute pain indicates the tissue damage or t he threat of such,
is time limited – does not last more than three months and
does not have long-term eects on the qual ity of the patient’s
life. It occurs as a preliminary or associated symptom
with many diseases; hence, it is not treated in clinical
practice prior to diagnosis. Acute pain is accompanied by
symptoms of the vegetal system including increased blood
pressure and heart rate, deepened breathing, enlarged
pupils, increased muscle tone [3, 5]. Its concurrence is
not related to age [1]. e key characteristics of acute pain
are warning and protecting against tissue damage, or
protection and a precaution for people with existing tissue
damage. Acute pain usually withdraws within a few to
several days. Lack of or improper treatment may lead to
transformation of acute pain into chronic pain [6].
•
Chronic pain, in accordance with the denition of the
Commission of Acute Pain in Elderly People of the
American Geriatric Society, is a pain without any tissue
damage, lasting more than three months [5]. Its frequency
increases with age [1]. Chronic pain aects 41% of people
Address for correspondence: Małgorzata Dziechciaż, NZOZ ‘DAR’, 3-go Maja 65,
37-500 Jarosław, Poland
e-mail: dziechciaz@vp.pl
Received: 14 Novem ber 2013; accepted: 29 Dece mber 2013
Ann Agric Envi ron Med. 2013; Special Issue 1
Małgor zata Dziechciaż, L uiza Balicka-Adam ik, Rafał Filip. The pr oblem of pain in old age
aged between 65 – 75, 48% of people aged between 75 –
84, and 55% of people over 85 years of age [1]. It occurs
among 45% – 80% of people residing in nursing homes
[5]. Research carried out in 15 countries in Europe and in
Israel indicated a high propagation of chronic pain and
its inuence on the quality of patients’ lives, and high
encumbrance to medical sector [7]. Cancer is a common
cause of chronic pain. It is experienced by 2/3 of patients
in the terminal stage and by 1/3 of patients in the early
stage of cancer [6]. e concurring symptoms include
insomnia, lack of appetite, anxiet y, problems with contacts
with friends, decreased interests, gradual increase in
despondence, despair, and lack of meaning of life [3].
A special type of pain is called ‘total pain’, also referred
to as ‘pervasive pain’. is is a multi-type pain, combining
the elements of acute and chronic pain, occurring mainly
in people diagnosed with malignant cancer or other lethal
diseases [8].
As for anatomical criteria, chronic pain may be divided
into recept ive (nociceptive) and non-receptive (neuropathic).
Receptive (nociceptive) pain results from stimulation of
pain receptors. It may occur as somatic or visceral pain.
Somatic pain comes from deeper tissue or skin tissue –
e.g. pain resulting from bone fracture, muscle spasms,
joints pain. Visceral pain results from damage to an organ,
system or tissue (e.g. pleura, peritoneum). Nociceptive pain
is commonly described as dull, gnawing, extensive [5, 8];
Non-receptive (neuropathic) pain results from lowering
the stimulus level of nociceptives or by damaging the
circumferential or central nervous system. It may be caused
by nerve damage during surgery, radiotherapy, medicine
or advancing disease. An example of neuropathic pain may
be neuralgia, radicular or phantom pain. Neuropathic pain
is described as burning, tingling, electrical, stabbing, heat
wave, pins and needles [8, 5].
In practice, it is common for chronic pain to possess
the characteristics of both nociceptive and neuropathic
pain; thus, it is oen impossible to classify it into only one
category[5].
Objective. e aim of the study is to present the frequency
of occurrence, classication and treatment of pain in old
age, based on the analysis of literature on the given subject.
INTRODUCTION
Research has proved that with age the sensation and reaction
to pain changes, the causes of which remain unclear [9]. In
accordance wit h many authors, in old age the pain threshold
is increased [10, 11, 15]. In the elderly, lowered reaction to
slight pain and increased sensitivity towards severe pain is
observed. In old age there are functional, structural and
biochemical changes to the circumferential ner vous system,
lowered density of myelinated and unmyelinated bres, and
neuronal damage, leading to worsening functioning, lowered
concentration and circulation of neurotransmitters i nvolved
in nociceptive the processes [9, 1].
People in old age are more prone to chronic pain.
Involutional changes of the organism and concurrence of
chronic disea ses favour such phenomena. e research results
indicate that approx. 85% of the elderly suer from pain [5].
Among the diseases with concurring pain, the most
signicant are diseases of the locomotor system, which aect
about 80% of the population over 70 years of age [1, 12]. ese
include: osteoporosis, osteoarthritis, rheumatoid arthritis,
and polymyalgia rheumatica [1, 13, 14]. With osteoporosis,
the pain is most frequently caused by vertebral fracture,
is sudden, located in the thoracic-lumbar area, and lasts
for up to few weeks [15]. Pain in rheumatoid arthritis is
most oen chronic, occurs and intensies with performing
even basic activities. With rheumatoid joints inammation,
polymyalg ia rheumatic, rest pain may be obser ved [16]. With
osteoarthritis, the pain is caused by pressure of disease-
related structure changes of the neurovascular bundle or
reexive muscular contraction. It is oen very severe and
thus reduces mobility [17].
With people in old age the pain is located in the areas of
joints, back and lower limbs [1]. People in the old age residing
at home more frequently suer from pain of the joints, lower
limbs and spine, whereas people residing in nursing homes
suer from pain of the joints, fractures and cancer [5].
e main cause of pain sensation with people in old
age is related to the locomotor system. ese pains are
degenerative, and in proli ferative changes a nd demyelination
of osteoart icula r system; also, non-organic causes such as fear
and depression play a signicant role [9]. A serious cause of
locomotor system injuries are falls classied as ‘signicant
geriatric symptom’. ey are caused by involuntary changes
of the central nervous system, worsening sight, hearing and
balance [10, 13].
Another geriatric problem related to pain is depression
[1], which aects approx. 15% of the population over 65
years of age. Very oen, the incidence among the elderly is
the occurrence of cryptic depression [18], and masked pain
manifested by chronic pains located in innervated sacral
plexus, brachial, ischiatic, intercostal and cranial areas.
Pain in depression may be located in the occiput area and
may radiate towards brachial and nucha. It may be a dull,
continuous pain, felt as a pressure or weight. In cryptic
depression, pain may also be in the form of paresthesia,
burning, tingling, sting, feeling of cold feet and ankles
[19]. Many authors have proved the relationship between
depression and occurrence of pain [1, 5, 19]. Chronic pain,
improperly treated, may lead to the creation of depression,
and the depression intensies the feeling of pain, thus
creating a ‘vicious circle’ [5, 1].
A frequent cause of pain in people in old age is related to
neuralgia, shingles, and diabetic neuropathy, leading to the
creation of neuropathic pai n manifested by burning, tingl ing,
heat wave, pins and needles, itching [5].
Pain assessment with people in old age is dicult and
requires vast experience. To assess the pain the following
must be considered: localization, intensity, timing, quality
(character) and reactions to pain [20, 5].
Assessment of pain localization is a base for preliminary
pain diagnosis. With people in old age with cognitive
disorders and depression the correct description of pain
areas is dicult [20, 5]. It is helpful to draw a sketch the body
on which the patient marks the painful areas [21].
Intensity of pain is related to various factors, namely: age,
gender, race, condition of the nervous system, genera l health
condition, and sensitivity to pain stimuli [19]. To assess the
intensity of pain, the following subjective scales may be
helpful:
36
Ann Agric Envi ron Med. 2013; Special Issue 1
Małgor zata Dziechciaż, L uiza Balicka-Adam ik, Rafał Filip. The pr oblem of pain in old age
• verbal scale – containing various expressions of the pain,
such as ‘no pain’, ‘slight pain’, ‘moderate pain’, ‘severe
pain’ [21, 5];
•
score scale – the patient is asked to assess the pain intensity
in the last 24 hours, where 0 means no pain and 10 the
worst pain a patients can imagine [5, 20, 21];
• Functional Pain Scale – can assess the pain intensity and
its inuence on everyday activities. In accordance with
this scale, ‘0’ means no pain with no inuence on everyday
activities; ‘1’ means tolerable pain with no inuence
on everyday activities; ‘2’ means tolerable pain which
inuences everyday activities; ‘3’ means intolerable pain
which does not prevent a telephone conversation, watching
television, or reading; ‘4’ means intolerable pain which
prevents a telephone conversation, watching television,
and reading; and ‘5” means intolerable pai n which prevents
verbal communication.’
Timing of pain enables dening whether pain is acute or
chronic, paroxysmal or continuous, spasmodic or continui ng
[20, 5].
Quality of pain, its character may be described as itching,
burning, radial, bursting, spastic, tearing [20, 5].
Multi-elementary method of pain assessment concerning
localization, charac ter, frequency and intensity is t he McGill-
Melzack Pain Questionnaire [5, 8]. Another questionnaire
to assess quantitative and qualitative scale of pain is the
McGill-Melzak Pain Questionnaire – MPQ. A simplied
Polish version of the McGill-Melzak Pain Questionnaire is
the Pain Assessment Questionnaire (in Polish: Arkusz Oceny
Bólu – AOB) [8].
A signicant problem which impedes pain assessment
with people in old age is dementia, which is believed to have
aected 3% – 11% of people of over 65 years of age, and over
20% – 50% of the population over 85 years of age [13]. Patients
with cognitive disorders may not be able to communicate
their pai n. erefore, it is utterly important to pay attention to
the following symptoms which may indicate pain sensation:
worsening appetite, anxiety, insomnia, agitation, grimaces,
gnashing teeth, sighing, moaning, deep breathing, resistance
to nursery activities.
For people with speech disorders, pain assessment may
be accompanied by visual scale representing faces – from
happy to bursting into tears, and questionnaires including
questions with ‘yes’ or ‘no’ answers [5].
In pain assessment, the awareness that pain has signicant
inuence on the patient’s life is very important; thus, physical
tness a nd limitat ions, social support and tre atment strateg ies
must be predened. e emotional and psychophysical
inuence of pain on the experiencing person must not be
omitted. e reactions to pain include: fear, angst, anger,
insomnia and loneliness [5].
In accordance with recommendations of the International
Association for the Study of Pain, pain treatment should be
multimodal, including not only somatic aspects but also
psychological, social and recreational [1]. Pain treatment
should include usage of both pharmacological and non-
pharmacological methods [5].
Pharmacology is the basis for pain treatment in people
of old age [1, 10]. e recommendations of the American
Geriatric Society in 2002, indicated the following:
• usage of the least invasive way of application;
•
if possible to choose medici ne with lasting eec ts, including
small dosages which may slowly be increased;
•
to leave longer intervals between introducing new
medicine, to properly assess eectiveness;
•
to constantly monitor and modify treatment to reduce
unwanted side-eects and increase eectiveness;
• if necessary to implement rotation of opioids [9].
e pain-relieving medicine of rst choice for the
pharmacologica l treatment of people in old age is paraceta mol
(analgesic). It is used specically with muscle-skeletal pains
of slight to mild intensity. It may be supported with weak
opioids, such as codeine or tramadol. Due to hepatotoxic
and nephrotoxic eects, it is advisable not to exceed the daily
dosage (4mg, and less with liver diseases) with concurrent
control of liver functioning [1, 10, 22, 23].
Another group of medicines used in pain treatment are
non-steroid anti-inammatory medicines (NLPZ) used
mainly with muscle-skeletal pains, and cancer pains with
bone metastasis [1]. It is advised to use a very cautious
approach in application with people in old age. Long-term
application of medicine exceeding maximal daily dosages
may cause numerous side-eects, including: digestive
system complications, psychic disorders, coagulation
disorders, kidney failure, thromboembolic complications,
and congestive cardiac failure [1, 10]. Unfortunately, despite
many contra-indications, they are used by approx. 50% of
the elderly [22].
Weak opioids, namely tramadol and codeine, are used in
the treatment of pain in the locomotor system as fundamental
or supportive treatment, especial ly in neuropathic pain [10].
Opioid usage should be considered with patients with mild
to severe pain, which impair functional activity and quality
of life [22]. Treatment with strong opioids (e.g. morphine)
should be considered only when other methods of treatment
had failed. Opioid therapy should not be used with patients
with dementia and dementure. Among the unwanted
side-eects of opioid usage are additions and respiratory
depression. Substantial problems of people in old who are
treated with opioid are sleepiness and confusion which
play a role in falls [10, 24]. In rare cases, chronic treatment
with opioids may lead to the occurrence of extrapyramidal
symptoms similar to Parkinson’s syndrome [25]. In opioid
treatment of the elderly, it is important to start with small
doses and slowly increase them, considering the possible
occurrence of potential unwanted side-eects, which must
be prevented and treated instantly [1].
Other groups of medicine include supportive medicine,
which have eects other than pain killers, but are proven
to be eective against neuropathic pain. e following are
antidepressants, anticonvulsants, lidocaine, mexiletine and
NMDA receptor antagonists are a few [1, 5].
Although pharmacology is fundamental in pain treatment
of people of old age, it is important to combine the treatment
with non-pharmacological ways of countermining pain,
which may signicantly reduce the amount of medicine
intake and provide the patients with the feeling of control.
Among non-pharmacological ways, the following can be
distinguished:
•
rehabilitation – including physical exercises, physical
methods, cryotherapy, electrotherapy, massages,
mobilisation and medical manipulation;
• occupational therapy – used to improve self-service and
provide independence;
37
Ann Agric Envi ron Med. 2013; Special Issue 1
Małgor zata Dziechciaż, L uiza Balicka-Adam ik, Rafał Filip. The pr oblem of pain in old age
•
psychological therapy – the most commonly used
behavioural therapy or cognitive-behavioural therapy,
relaxation therapy and biofeedback;
•
complementary and alternative therapy – acupuncture,
homeopathy, spiritual support [1, 5].
•
therapeutic fasting – voluntary resignation from food
consumption over a specic period of time for therapeutic
purposes. Due to fasting, approx. 300 kcal/day is lost. It
is recommended in rheumatoid arthritis, migraine and
chronic pains [26].
Independence, the possibility of doing everyday activities
and favourite actions are crucial for patients in old age; thus,
even a slight possibility of improving functional activity
may greatly enhance the pain control. In pain treatment,
awareness among the elderly, their families and carers, and
medical sta that the pain is not an attribute of the old
age of, thus it should be correctly diagnosed and treated.
Unfortunately, in real life, as commonly as concurrence
of pain among seniors, there is improper or lack of pain
treatment [5].
DISCUSSION
Old age predisposes for frequent occurrence of chronic
pain connected with both involuntary changes of the elder
organism and with multiple morbidities characteristic of
that period of time. e pain assessment of people in old
age is dicult, and therefore requires vast experience. It
is signicant to include the possibility of expressing pain
and attracting attention to objective pain symptoms. Pain
treatment of old people should be multi- disciplinary and
include both pharmacological and non-pharmacological
treatment. Awareness should be ra ised that for pain treatment
the possibility of improving functional activity may greatly
enhance the pain control.
CONCLUSIONS
1. Old age predisposes to the occurrence of chronic pain.
2. e sensation and reaction to pain changes with age.
3.
Pain classication in people of old age, especially with
cognitive d isorders, is dicult and requ ires vast experience.
4. Pain treatment of people in old age should be multimodal
and include usage of both pharmacological and non-
pharmacological methods of treatment.
REFERENCES
1. Wordliczek J, Dobrogowski J. Analgesic Pain Treatment. In: Grodzki
T, Kocemba J, Skalska A (eds.). Geriatrics with elements of general
gerontology. Cour se book for doctors and s tudents. Via Medic a, Gdańsk
20 0 7.
2.
Pyszkowska J. Pathomechanism of pain and the essence of total
suering. In: De Walden- Gałuszko K, Kopacz A (eds.). Nursing of
hospice and pa lliative c are. Wydawnic two Lekars kie PZWL , Warszaw a
2005.
3. Seemann H. Care of patients with chronic pain. In: Kaplun A. (eds.).
Promoting health in chronic conditions. Ocyna Wydawnicza
Insty tutu Medycyny Pracy, Łódź 1997.
4.
Muller A. Physiology of pain. In: Saint – Maurice C, Muller A,
Meynadier J. Pain, diagnosis, treatment and prevention. Gebethner
ex S-ka, Warszawa 1998.
5.
Temporal Michael T. Pain treatment. In: Rosenthal T, Naughton
B,Williams M. Geriatrics. Wydawnictwo Czelej, Lublin 2009.
6. Korzeniowska K, Szałek E. Ból. Modern pharmacology 2010; 3: 9–10.
7.
Styczy ński T. Advanc es in treat ment of spondyloar thrit is. Rheu matology
2013; 51(6): 429–436.
8. Pyszkowska J. Possibilit ies to assess chronic pain. Objective approach
to scoring using modied pain assessment questionnaire. Psycho
oncology. 1999;4: 13–27.
9. Pergolizzi1 J, Böger RH, Budd K, Dahan A, Erdine S, Hans G, Kress
HG, Lang ford R, Likar R , Raa RB, S acerdote P. Opioids and treatment
in severe chronic pain with elders. Palliative medicine in practice
2009; 3(1): 40–66.
10. Gasik R, Styczy ński T. Specics of pha rmacological t reatment of back
pains in people of old age. Polski Merkuliusz lekarski 2006; 21(124):
394 -397.
11. Kołodziej W. Bio psycho social functioning of people in old age and
social stereotypes and prejudice concerning ageing and old age. In:
Nowicka A (eds.). Selected problems of people in old age. Ocyna
Wydawnicza Impuls, Kraków 2006.
12. Doroszkiewicz H, Bień B. e prole of behaviour of people in old
age struggling with pain of locomotor system. e nursing problems
2010; 18(3): 260–265.
13. Dziechciaż M, Płaszewska-Żywko L, Guty E. Most common diseases
of old age in popu lation of rural a reas. In: Talarska D, Wieczorowska-
Tobis K. Man of old age in modern society. Wydawnictwo Naukowe
Uniwersytetu Medycznego im Karola Marcinkowskiego w Poznaniu,
Poznań 2009.
14.
Jasik A, M arcinowska-Such owierska E. Joint p ains of people in old age .
Progress in Medicine 2011; 5: 402–409.
15.
Galus K. Osteoporoza. In: Grodzki T, Kocemba J, Skalska A (eds.).
Geriatrics with elements of general gerontology. Course book for
doctors and students. Via Medica, Gdańsk 2007.
16. Głu szko P. Rheu matic diseas es. W: Grodzki T., Kocemba J., Sk alska A.
(eds.). Geriatrics with elements of general gerontology. Course book
for doctors and students. Via Medica, Gdańsk 2007.
17. Głuszko P. Diseases of Joint degeneration. In: Grodzki T, Kocemba
J, Skalska A (eds.). Geriatrics with elements of general gerontology.
Course book for doctors and students. Via Medica, Gdańsk 2007.
18.
Dudek D, Zięba A, Siwek M, Wróbel A. Depression. In: Grodzki
T, Kocemba J, Skalska A (eds.). Geriatrics with elements of general
gerontology. Cour se book for doctors and s tudents. Via Medic a, Gdańsk
20 0 7.
19.
Chodorowski Z. Main masks of depression of patients in old age.
Advances of Psychiatr y and Neurology 1998; 7(6): 41–46.
20.
http://ww w.pfm.pl/u235/navi /201246/back/2 00280 (access: 17.08.2012).
21.
http://www.elsevier.pl/layout_test/book_file/35/Choroby-wewn-
Davidsonarozdział.pdf (access: 17.08.2012).
22. Wieczorowska -Tobis K. Palliative medicine and c are at the end of life
of the elders. Geriatrics 2009; 3: 133–138.
23.
Wieczorowska-Tobis K, Rajska-Neumann A. Pain as the cause of
cognitive function disorders of people in old age. Geriatrics 2010; 4:
292–294.
24. Dobrogowski JL, Kocot-Kępska M, Przeklasa Muszyńska A. Usage of
oxycodone with naloxone (Targin) with chronic pain patient – case
study. Palliative medicine 2001; 5(3): 123–128.
25.
Niedzia łek D, Tłustochow icz W. Pain t reatment of rheumat ic diseases .
Progress in Medicine 2012; 2: 109–114.
26.
Chmara E, Cieślewicz A. Non-pharmacological methods of pain
treatment. Contemporary Pharmacy 2010; 3: 15–19.
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