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Understanding the Older Patient With Pain

Chronic pain affects all segments of the population, but of course older adults are more likely to be impacted, particularly by joint pain and other forms of musculoskeletal pain. In some studies, up to 50% of the older population reports clinically significant pain.  Those numbers go even higher in nursing home residents where the reported rate is as high as 80%. So, given that the population as we know is aging, we need to be prepared to manage pain in this segment of the population.

When we think about how our bodies perceive pain and handle pain signals, we have one system to amplify pain to let us know and take corrective action, and balancing that, we have a pain inhibition system to diminish the amount of pain that we experience.  In healthy, younger adults, those systems are in balance so that we can feel pain when we need to, but we can also control our own pain and move on with our lives.  What we see with age is we get better at increasing the pain and we get worse at decreasing the pain, which puts older adults at risk for experiencing higher levels of pain given the same type of injury or extent of injury. This pain modulatory imbalance can be a problem that we need to address in pain management for older adults. There are a variety of biopsychosocial factors at work in creating this imbalance.

On the biological side, systemic inflammation is increased in older adults, in fact it’s been termed “inflammaging.”  We see changes in the function and the structure of peripheral nerves that transmit pain signals, changes in brain structure and function. In fact, gray matter atrophy in certain regions of the brain may be associated with increased levels of pain in older adults. There are also psychosocial changes as we age.  We may cope with pain differently, older adults tend to be more likely not to report pain and may be at risk for not getting their pain managed. In older adults, depression is certainly a risk factor for chronic pain, as well as their social environment where isolation is more likely. Those things too put older adults at increased risk for chronic pain.

When creating a treatment plan for older adults, we need to address both the biological and the psychosocial factors, so that may point to medical therapies or other types of invasive treatments but also non-pharmacological therapies, exercise interventions, cognitive behavioral interventions, problem solving interventions, even interventions directed toward having older adults increase their social engagement and seek out social support to help them manage their pain conditions.

And the other thing we need to think about as providers is that assessment of pain in older adults may require more intensive probing, different types of pain scales, different questions about pain in order to really get the information we need. Finally we need to recognize that there can be cognitive changes in older adults; perhaps more rigid thinking, reduced short-term memory, so we may need to tailor our treatment plan, and our

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