Keeping Watch on Pain in Older Adults

Chronic pain becomes more common as people grow older, at least in part because of health problems, such as osteoarthritis, that become more prevalent. Military veterans are another group at increased risk for chronic pain. There is almost always a real problem behind pain. Stemming from an underlying disease or health condition, medical treatment (such as surgery), an injury, inflammation, a problem in the nervous system, or the unknown, pain can be accompanied by difficulty in moving around, disturbed sleep, anxiety, depression and other problems that can affect quality of life. Pain rarely exists in isolation and, in older adults, pain often accompanies multiple chronic conditions, including diabetes, depression, heart disease and chronic obstructive pulmonary disease. Falls, injuries and acute illnesses are also correlated with pain symptoms. Controlled prescription drugs, such as opioid analgesics, benzodiazepines (BNZ) and non-benzodiazepine hypnotics (NBNZH), are frequently prescribed to older adults. Those studying the issue say use of these medications poses potential adverse consequences because of the increased risk for cognitive decline, falls and misuse or dependence, in addition to the risk of medical burden, functional impairment and multiple concomitant medications, known as polypharmacy, which can lead to dangerous drug interactions. A 2017 study focused on a sampling of Medicare homecare patients under the care of 132 homecare agencies that subscribed to Brightree software services. The study reported that while prescription opioids are often clinically indicated, the high prevalence among this population underscores the role of home health clinicians in follow-up and post-discharge care. The study, which was funded by grants from the National Institute of Mental Health and from the National Institute on Aging at the National Institutes of Health, noted surgical aftercare, rehabilitation and osteoarthritis as the top diagnoses tied to the highest rates of prescription opiates. The Agency for Healthcare Research and Quality (AHRQ), the lead federal agency charged with improving safety and quality in health care, recently reported new insights into how seniors struggling with opioids has become an urgent public health problem. The AHRQ’s September 2018 report measuring prescription opioid use among seniors in the noninstitutionalized population estimates that nearly 1 in 5 senior adults, on average, filled at least one opioid prescription in 2015 and 2016 and that 7 percent of seniors filled four or more opioid prescriptions, which was considered to be “frequent use.” Among other findings, report authors found frequent use of opioids was more likely among seniors who were poor or low income compared to those who were middle or high income; more likely among seniors with Medicare and other public insurance compared to those who had Medicare only or Medicare and private insurance; and more likely among seniors living in rural areas compared to those living in urban areas. “The challenge is safe prescribing for those who need opioids for pain while avoiding overuse or misuse,” AHRQ Director Gopal Khanna, MBA, said at the time. Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse or overdose from these drugs, says the Centers for Disease Control and Prevention. The CDC offers its Guideline for Prescribing Opioids for Chronic Pain to provide recommendations for prescribing such medication for patients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than three months or past the time of normal tissue healing) outside of active cancer treatment, palliative care and end-of-life care.

What Caregivers Can Do

Generally speaking, individuals respond differently to pain and pain relief. Caregivers can help by believing and learning more about reported pain. Health in Aging, a resource created by the American Geriatrics Society’s Health in Aging Foundation, offers the following: “Pain is whatever a person says it is and exists whenever he or she says it does.” While national health professional organizations have issued guidelines for treating several chronic pain conditions, some mention ways in which certain complementary health approaches can be incorporated into treatment plans. Others discourage the use of certain complementary approaches. For example, the American College of Rheumatology mentions several complementary approaches in its guidelines for the management of osteoarthritis of the hip or knee. For osteoarthritis of the knee, the guidelines mention tai chi as one of several nondrug approaches that might be helpful. The same guidelines, however, discourage using the dietary supplements glucosamine and chondroitin for osteoarthritis of the hip or knee.

Relieving Pain Without Medication

Nonpharmacological pain management approaches do not use medications. Stanford Health Care describes methods such as education and psychological conditioning; hypnosis; comfort therapy, which includes companionship, exercise, heat/cold application, lotions/massage therapy, meditation and positioning, for examples; physical and occupational therapy; and neurostimulation, such as transcutaneous electrical nerve stimulation (TENS), acupuncture and acupressure. Pain management in older adults has been in focus since at least 2010 when the Center for Drug Evaluation and Research’s (CDER) Safe Use Initiative team convened a roundtable of more than 40 experts from academia, health care management, consumer advocacy and government to address the safe use of pain medications in older adults. At that time, the facilitated discussion addressed primarily the gaps in knowledge in treating older adults with pain; the undertreatment of pain; and the use and misuse of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) in older adults. Some of the challenges identified in the 2010 discussion were the severity of opioid side effects in older people and the lack of adequate monitoring of patients who receive opioid prescriptions. Since then, the NIH has developed the National Pain Strategy, a comprehensive plan to improve the assessment and care of people with pain, and starting Jan. 1, 2019, Medicare drug plans must follow new opioid overutilization policies. Research from the CDC showed that in 2015 Medicare beneficiaries accounted for 30.5 percent of hospitalizations related to nonfatal drug overdose, while Medicaid beneficiaries accounted for 31.6 percent. The new Medicare Part D opioid overutilization policies encourage interdisciplinary collaboration as well as care coordination among Part D plans, pharmacies, prescribers and patients in improving opioid utilization management, preventing opioid misuse, reducing serious adverse risks and promoting safer prescribing practices.

Before Trying a New Pain Strategy

Home health clinicians are well-positioned to help evaluate pain, and review and identify appropriate and potentially inappropriate medication and strategies. In other areas of medical care, enthusiasm for new treatments, for example, is considered a driver of use and overuse, but evidence can sometimes be lacking with new approaches. Before trying or recommending any new therapy for pain management and control, it is best to consult with a qualified physician or other health care professional. The vendor views found here may also be helpful.