The British Pain Society is very pleased to endorse these authoritative evidence-based guidelines, which promise to tangibly improve the lives of the increasing number of older adults living with painful conditions.
There have, however, been an increasing number of studies into the prevalence of pain in older people in the last decade or so. Until recently, our knowledge of the prevalence of pain in older people, particularly those in the oldest age group, was relatively poor. Pain tended to be considered to be part of the ageing process and was rarely investigated in its own right.
Opioid therapy may be considered for patients with moderate or severe pain, particularly if the pain is causing functional impairment or is reducing their quality of life. Opioid side effects including nausea and vomiting should be anticipated and suitable prophylaxis considered. However, this must be individualised and carefully monitored. Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people who are prescribed opioid therapy.
Mindfulness and meditation i20.
Spinal cord stimulation i15.
Appendix 3: Matrices i35.
Studies in English language.
Methodological challenges to measuring pain prevalence i5.
Attitudes and beliefs i6 Review i6 Communication i7 Pharmacology i8 Results i8.
Professor David Oliver, National clinical director for older people department of health.
The biopsychosocial aspects of pain are further addressed by way of the document's comprehensive review of the evidence for or against a wide range of treatments specifically for the management of pain in older adults, including complementary therapies, the benefits of patient education and self-management techniques, psychological and physical as well as pharmacological options and interventional techniques.
Sympathectomy for neuropathic pain i15.
Any disagreements between scoring would be mediated by another group member. All papers that were considered to be acceptable were incorporated into the matrices (Appendix 3) and were then included in the commentary which follows. A score was assigned to each paper and the papers were then exchanged among the group and another reviewer independently assigned a score. There were no disagreements.
Specific pathologies = 0.
Mrs Jean Gaffin, Lay Representative.
Such approaches can affect pain and anxiety and are worth further investigation. A number of complementary therapies have been found to have some efficacy among the older population, including acupuncture, transcutaneous electrical nerve stimulation (TENS) and massage.
Dr Alison M Elliott, PhD, BSc (Hons), Senior Research Fellow, Centre of Academic Primary Care, University of Aberdeen.
Appendix 2: Level of evidence i35.
We have substantive evidence to show that pain in our older patients is not recognised or managed as well as it would be in younger adults. This evidence base needs to take into account the similarities in effective assessment and management of pain between older and younger people, but also the differences in approach sometimes required to take into account poor reserve, altered pharmacokinetics and dynamics, drug–drug and drug–disease interactions, adherence and the difficulty in assessing pain in those with atypical presentations or impaired cognition or communication. As people over 65 account for 65% of admissions to hospital, ∼40% of primary care spend and the overwhelming majority of long-term care residents and users of community health services, clinicians need to adjust to this reality and to ensure they have the right skills, knowledge and evidence-base to deliver effective care.
Dr Liz Sampson, MD MRCPsych, Senior Clinical Lecturer, Marie Curie Palliative Care Research Unit, Research Department of Mental Health Sciences, University College London Medical School.
Physiological changes in older people that affect drug handling i8.
It is, however, important that the maximum daily dose (4 g/24 h) is not exceeded. Evidence from the literature search suggests that paracetamol should be considered as first-line treatment for the management of both acute and persistent pain, particularly that which is of musculoskeletal origin, due to its demonstrated efficacy and good safety profile. There are few absolute contraindications and relative cautions to prescribing paracetamol.
Physiotherapy and rehabilitation = 260.
Dr Margaret Bone, FRCA FFPMRCA Consultant in Pain Medicine, University Hospitals of Leicester.
Complementary therapies = 171 Guidelines = 162.
Interventional therapies in the management of chronic, non-malignant pain in older people i13.
Self-management of pain i22 Complementary therapies i22 Acupuncture i23.
These guidelines will be updated in 3 to 5 years.
Professor Denis Martin, DPhil, MSc Applied Statistics, BSc (Hons) Physiotherapy Professor of Rehabilitation, Health and Social Care Institute, Teesside University.
There are many areas that require further research, including pharmacological management where approaches are often tested in younger populations and then translated across. Prevalence studies need consistency in terms of age, diagnosis and terminology, and further work needs to be done on evaluating non-pharmacological approaches.
The two main databases searched were PubMed and CINAHL. AMED, PsycInfo and Scopus were also used to refine some of the searches.
The current evidence for the use of epidural steroid injections in the management of sciatica is conflicting and, until further larger studies become available, no firm recommendations can be made. There is, however, a limited body of evidence to support the use of epidural injections in spinal stenosis.
TENS/PENS (transcutaneous/percutaneous electrical nerve stimulation) i23 Massage i23 Reflexology i23 Guidelines i23 Acknowledgements i24 References i24 Appendices i33.
Similarly, each total includes references found in other topics' totals. Note that these totals include duplicates in those searches where more than one database was used.
Richard Langford, President of the British Pain Society.
These comprehensive guidelines, developed by a multi-disciplinary team, provide a superb, user-friendly resource for clinicians treating pain in older patients in all settings and I have certainly learned a lot by reading them that will inform my own clinical practice. They deserve a wide audience.
Non-steroidal anti-inflammatory drugs i9 Opioids i9 Adjuvant drugs i11 Topical therapies i12.
Dr Roger Knaggs, BSc BMedSci PhD MRPharmS, Advanced Pharmacy Practitioner—Pain Management, Nottingham University Hospitals NHS Trust, Nottingham.
Further non-PubMed and non-CINAHL results were found in PsycInfo and AMED, but exact numbers are not available. Approximay 5,000 records were found. A separate search of Scopus, which found 7,472 records, was used only to refine the results of one of the search topics, and may have found items missed by the other databases. The main PubMed search found 3,691 records and the CINAHL search found a further 837 records, giving a total of 4,528 returned by the core searches.
Assistive devices, often overlooked in research and guidelines documents, are critically appraised and highlight the small amount of evidence available in this area, that suggests benefit in supporting community living and reduction in functional decline, care costs and pain intensity.
It is a privilege to provide a foreword for this landmark publication on the management of pain in older adults: a most important field of practice, and currently an area of significant unmet need in the community, secondary and social care settings. There is a need to improve awareness and implement assessment tools and appropriate treatments, to alleviate suffering and improve the quality of life.
Radiofrequency denervation of Gosserian ganglion to treat trigeminal neuralgia i18 Psychological interventions i19.
General principles of pharmacological management of pain in older people i8 Paracetamol i8.
Prevalence of pain in older people i5.
Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in older people after other safer treatments have not provided sufficient pain relief. All older people taking NSAIDs should be routinely monitored for gastrointestinal, renal and cardiovascular side effects, and drug–drug and drug–disease interactions. For older adults, an NSAID or cyclooxygenase-2 (COX-2) selective inhibitor should be co-prescribed with a proton pump inhibitor (PPI), and the one with the lowest acquisition cost should be chosen. The lowest dose should be provided, for the shortest duration.
Dr Derek Jones, Senior Lecturer, Northumbria University, School of Health, Community and Education Studies.
Palliative care = 225.
The focus on the management of pain in older adults continues by examining the place of a variety of commonly employed procedures for pain, from simpler interventions such as intra-articular injections to sophisticated approaches such as spinal cord stimulation. These are usefully and appropriay reviewed together with some of the common and bothersome painful conditions affecting older people, such as back pain, post-herpetic neuralgia and trigeminal neuralgia.
Separate, specific search strategies were used for each of the nine sub-topics for which searches were conducted.
Interventions and specific comparisons to be made: all drug and non-drug intervention studies, including comparisons with placebo, standard care and waiting list control.
Following acceptance of papers, each author graded the papers according to the following system, as proposed by Harbour and Miller :
Poor control of pain has consistently been identified as an issue for older people and their carers in hospital settings and as a life-limiting factor which can trigger a spiral of dependence and depression. For all this good news, if people live long enough, they are more likely to develop multiple long-term conditions, a degree of disability or frailty, dementia or cognitive impairment and worsening mobility. They are also at risk of chronic and life-limiting pain from a variety of causes, of acute pain associated with injury or illness and of pain towards the end of life.
Stoicism is particularly evident within this cohort of people. The three most common sites of pain in older people are the back; leg/knee or hip and ‘other’ joints. In common with the working-age population, the attitudes and beliefs of older people influence all aspects of their pain experience.
Gender differences in pain prevalence in older people i5.
Communication and self-management = 333 Pharmacology = 191.
The important influences of attitudes and beliefs of older people in relation to pain and the presence of stoicism in this age group are discussed.
Increasing activity by way of exercise should be considered. Patient preference should be given serious consideration. However, they do not necessarily reduce pain and can increase pain if used incorrectly. The literature review suggests that assistive devices are widely used and that the ownership of devices increases with age. Such devices enable older people with chronic pain to live in the community. This should involve strengthening, flexibility, endurance and balance, along with a programme of education.
Viscosupplementation (intra-articular hyaluronic acid injection) i17 Post-herpetic neuralgia i17.
Professor Nicola Adams, BSc (Hons) MCSP PhD CPsychol, Professor of Rehabilitation, Northumbria University, School of Health, Community and Education Studies.
Intra-articular peripheral joint injections i16 Corticosteroids i16.
Age differences in pain prevalence in older people i5.
Types of participants: all adults over 65 years with chronic pain, living in the community.
Vertebroplasty and balloon kyphoplasty i16.
Number of papers by themes Prevalence = 444.
This represents a success for society and wider determinants of health, but also for healthcare—both preventative and interventional. Population ageing is a ‘game changer’ for our health services. Life expectancy at birth in England is now 82 for women and 77 for men. Nearly a quarter of our population is over 65 and the fastest growing group is the over 80 s—whose numbers have doubled over the past two decades. And most older people report high levels of happiness and of satisfaction with their own health, wellbeing and independence.
Intra-articular corticosteroid injections in osteoarthritis of the knee are effective in relieving pain in the short term, with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects. Intra-articular hyaluronic acid appears to have a slower onset of action than intra-articular steroids, but the effects seem to last longer. It should be considered in patients who are intolerant to systemic therapy.
Substantial differences in the population, methods and definitions used in published research makes it difficult to compare across studies and impossible to determine the definitive prevalence of pain in older people. There is, however, some evidence that the prevalence of pain is higher within residential care settings. There are inconsistencies within the literature as to whether or not pain increases or decreases in this age group, and whether this is influenced by gender.
The search used in CINAHL was elderly or older or geriatric* or ‘senior citizen*’
Types of study: randomised controlled trials (RCTs), cohort studies, non-experimental studies and descriptive studies.
Appendix 1: Specific search strategy for each section i33.
Dr Aza Abdulla, FRCP(UK), FRCP(I), MSc (Brunel), MSc (Med Ed, Cardiff) Consultant Physician, South London Healthcare NHS Trust, Kent.
This guidance document reviews the epidemiology and management of pain in older people via a literature review of published research. The aim of this document is to inform health professionals in any care setting who work with older adults on best practice for the management of pain and to identify where there are gaps in the evidence that require further research.
Papers were rejected that did not meet the following inclusion criteria:. The professional groups included epidemiology, geriatric medicine, pain medicine, nursing, physiotherapy, occupational therapy, psychology, pharmacy and service users. These key terms can be found in Appendix 1. Each group member identified initial approaches to the management of pain in older adults that would enable searching. A group was formed of key personnel from either care of older people, pain or both. They then provided key terms to allow the information scientist to conduct the review. Reference lists were given to each group member, who reviewed the lists and selected appropriate papers to include.
Studies included in the review i5.
But, tolerability and adverse effects limit their use in an older population. Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain.
The search used in PubMed was (((older person*) OR (GERIATRIC*) OR (elderly)) OR (SENIOR CITIZEN*)) AND (PAIN).
Barriers, attitudes and education = 0.
With older adults this can be particularly challenging due to age-related changes in vision, hearing and cognition. The emphasis, however, is on chronic pain management. Pain is described as an ‘unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage’. As we go into older age, it is suggested that many people have pain which is often ‘expected as part of ageing’ or something that they have to ‘learn to live with’. The assessment of pain has been addressed elsewhere ( http://www.britishpainsociety.org/pub_professional.htm#assessmentpop ); this document focuses on the management of pain. One of the fundamental issues regarding pain management in any age group is the assessment of pain. Millions of people in the UK live with chronic pain.
The assessment of pain in older people has not been covered within this guidance and can be found in a separate document ( http://www.britishpainsociety.org/pub_professional.htm#assessmentpop ).
Professor Finbarr Martin, President of the British Geriatrics Society.
Exercise and physical activity i21.
A publication date range of 1997–2009 was used. Further inclusion and exclusion criteria were decided during the appraisal stages. No other inclusion/exclusion criteria were used during the searching stage.
Sites of pain in older people i5.
The therapeutic advice is clear and accessible. It offers advice and information valuable to a wide range of readers. The scholarly reviews show, however, that there is need for further research on nearly every aspect of the issue. For example, frail older people, such as care home residents or older people with cognitive impairment, are particularly likely to get a poor deal at present. So a broad perspective is needed, and the broad array of disciplines and experts has made this possible. I am delighted that British Geriatrics Society is included. I welcome this guidance. This is important as although pain is common, it may be under-reported, and make itself apparent in a variety of ways to a variety of clinical and social care staff. We need to develop ways to enable their experience to be better noticed and understood, and then their needs better addressed. Interdisciplinary work is our best way forward.
This definitive work is the culmination of a colossal effort by a multi-disciplinary working group (comprising expertise in epidemiology, geriatric medicine, pain medicine, nursing, physiotherapy, occupational therapy, psychology, pharmacy and patient representation) to gather, digest and sift the evidence, to review the epidemiology of pain in older adults and underpin recommendations for best practice.
Prevalence of pain shown in studies i5.
Secondary outcomes included reductions in pain-related distress, disability, depression, quality of life and self-efficacy. The primary outcomes included measure of pain, for example, visual analogue scales or the McGill Pain Questionnaire (MPQ).
Intervention and invasive = 194 Psychiatry = 553.
Epidural steroid injections in spinal stenosis and sciatica i13 Epidural adhesiolysis i14.
Dr Pat Schofield, RGN PhD PGDipEd DipN, (CHAIR) Professor of Nursing, Centre of Health & Social Care, University of Greenwich.
There is also some evidence supporting the use of cognitive behavioural therapy (CBT) among nursing home populations, but of course these approaches require training and time. Some psychological approaches have been found to be useful for the older population, including guided imagery, biofeedback training and relaxation.
Continuous neuraxial infusions i15.
Facet joint injections i14.
Guided imagery and biofeedback i20 Assistive devices i20 Review i21.
Cognitive behavioural therapy i19.Oxycodone use in the elderly