Treatment of Pain in the Older Adult

Treatment of Pain in the Older Adult Hershl Berman, MD, FRCPC, Department of Internal Medicine, Department of Psychosocial Oncology and Palliative Care, University Health Network,Toronto, ON. Shawna Silver, BASc, PEng, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON. PAIN Strong opioid ± Nonopioid ± Adjuvant Weak opioid ± Nonopioid ± Adjuvant Nonopioid ± Adjuvant 1 2 3 Pain persisting or increasing Pain persisting or increasing Introduction There are a number of challenges to treating pain in older patients. As people age, the number of medical problems they have increases and they tend to be on more prescription drugs.1 Inappropriate prescribing of medications can increase the risk of drug interactions with potentially serious side effects. Before any treatment is started, it is essential to take a complete medication history. Hearing impairment can make it very difficult to get a good history. In addition, mild to severe cognitive impairment may make it impossible to properly treat the patient without assistance. Patients may forget what medications they take, or they may be unable to express themselves. Dementia can lead to difficulties with compliance as well. It is important that an interdisciplinary team approach be taken. The physician may or may not coordinate the team. The pharmacist can be asked to prepare blister packages to help with compliance. A visiting nurse can assess compliance and ensure effective symptom control. Caregivers play a vital role. They spend a lot of time with the patient and can answer questions that the patient cannot. They can bring the patient’s medications, take down instructions, and help to ensure compliance. A final challenge is the ability of the physician. Pain management is poorly taught in medical school and residency. For instance, an unpublished survey distributed by the author in 2001 revealed significant deficiencies in basic knowledge, including assessment of pain and the appropriate use of opioids. The following paper will discuss an approach to pain in the older patient. Although it is similar to the treatment of pain in younger people, there are a few key points that must be noted.