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. 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). 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 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. There is, however, some evidence that the prevalence of
pain is higher within residential care settings. 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. Stoicism is particularly evident within this cohort of people. 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. It is, however, important that the maximum daily dose (4 g/24 h) is not exceeded. 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. The lowest dose should be provided, for the shortest duration. 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. All older people taking
NSAIDs should be routinely monitored for gastrointestinal, renal and cardiovascular side effects, and drug–drug and drug–disease interactions.
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. However, this must be individualised and carefully monitored.
Opioid side effects including
nausea and
vomiting should be anticipated and suitable prophylaxis considered. 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.
Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of
neuropathic pain. But, tolerability and adverse effects limit their use in an older population. 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. It should be considered in patients who are intolerant to systemic
therapy. Intra-articular
hyaluronic acid appears to have a slower onset of action than intra-articular
steroids, but the effects seem to last longer. 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. 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. However, they do not necessarily reduce
pain and can increase
pain if used incorrectly. Increasing activity by way of exercise should be considered. This should involve strengthening, flexibility, endurance and balance, along with a programme of education. Patient preference should be given serious consideration. 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. Such approaches can affect
pain and anxiety and are worth further investigation. Some psychological approaches have been found to be useful for the older population, including
guided imagery,
biofeedback training and relaxation. 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. 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.