Introduction

Acute pain is a significant problem for older adults in both the hospital and the community. Acute pain is often associated with multiple chronic illnesses and surgical interventions and is a common reason for emergency department visits among the elderly.1,2  Unfortunately, elderly patients often fail to receive adequate management for pain when seeking care and are 20% less likely to receive treatment than younger patients. Many older adults subsequently leave the emergency department with unresolved pain.1 Effective treatment of acute pain is essential for this population, as unrelieved pain may lead to development of persistent pain, longer lengths of stay in the hospital, onset of delirium, compromised participation in physical therapy sessions, delays in ambulation, atelectasis, and functional decline.1,2

Current practices of pain assessment and reassessment in frail elders are largely considered to be inadequate.2 While nurses may not be assessing pain in older adults as frequently as is recommended, many older adults with moderate-to-severe cognitive impairment also are unable to adequately communicate their pain level.1,2 Patients who are cognitively intact will be able to quantify their pain using the verbal Numeric Rating Scale, but nurses and providers will need to use behavioral observation to identify the presence of pain in hospitalized older adults exhibiting acute confusion and those with a diagnosis of dementia.1,2 The most commonly used pain assessment tool used in the clinical setting for this population is the Pain Assessment in Advanced Dementia (PAINAD) scale.1

Interprofessional Assessment and Collaborative Interventions

Pain control in older adults also necessitates striking a balance between achieving pain relief and avoiding unwanted side effects. Older adults may be especially sensitive to certain analgesics given age-related physical changes that affect drug metabolism and clearance from the body. Subsequently, these patients may risk oversedation, respiratory depression, acute kidney injury, and gastrointestinal bleeding with these medications.1 Providers should consult with pharmacist to choose an appropriate medication at a safe, low starting dose that may be titrated according to patient response. The team will also need to consider the patient’s history, comorbid medical conditions, and current medications to choose an analgesic that will carry low risk of adverse drug interactions.3 Acetaminophen is considered the safest analgesic for older patients with acute pain given the absence of gastrointestinal, renal, and cardiovascular risks with appropriate dosing.For older adults with acute moderate to severe pain, opioids remain the standard of care although they carry risks of constipation, respiratory depression, and substance dependence that must be regularly assessed by nurses and providers.1,2 Nurses and providers are also encouraged to use complementary, non-pharmacological strategies such as positioning, massage, use of heat/cold, physiotherapy, cognitive behavioral approaches, and acupuncture to address pain.1,3

It is important that older patients presenting with acute pain follow-up with primary care providers after discharge for continued assessment and monitoring of treatment with analgesics.For patients who feel apprehensive about taking opioids for pain, it may be helpful to involve the social work team in addressing their concerns. For patients with cognitive impairment who are unable to quantity and express pain level, family members and caregivers play an invaluable role in informing nurses and providers about patient’s baseline behavior and activity level to identify variations that may indicate pain.2 There is also a need for staff education in hospitals and in the community surrounding pain assessment in older adults and development of pain assessment strategies that are time efficient and easily communicated across health care providers and settings.1,2

Interprofessional contacts for this topic:

Acute care providers

Primary care providers

Pharmacists

Pain management experts

Registered nurses

Social workers

Link to the following evidence-based protocols:

Assessing cognition

Medication

Pain

References

1Hwang, U., & Platts-Mills, T.F. (2013). Acute pain management in older adults in the emergency department. Clinics in Geriatric Medicine, 29(1), 151-164.

2Herr, K., Titler, M.G., Schilling, M.L., Marsh, J.L., Xie, X., Ardery, G., ... & Everett, L. Q. (2004). Evidence-based assessment of acute pain in older adults: current nursing practices and perceived barriers. The Clinical Journal of Pain, 20(5), 331-340.

3Abdulla, A., Adams, N., Bone, M., Elliott, A.M., Gaffin, J., Jones, D., ... & Schofield, P. (2013). Guidance on the management of pain in older people. Age and Ageing, 42, i1-57.