GRON 3112

Basic Care in Gerontology

Week 10
08 Nov 2022
Pain management for older adults
Mr. CP Chiu
 Content
• Types of pain
• Physiology of pain
• Common pain among elder person
• Barrier and challenge of pain management in older person
• Pain assessment tool
• Nonpharmacologic pain management
• Gate Control Theory of Pain
• Pharmacologic pain management
Types of pain in terms of duration
• Acute pain vs chronic pain

• Acute pain
• Usually comes on suddenly and is caused by something specific, e.g
surgery, broken bones, dental work, burns or cuts etc..

• Usually sharp in quality.

• Lasts < 6 months (some studies < 3 months)
• After acute pain goes away, life as usual.
(Cleveland Clinic, 2020)
Types of pain in terms of duration
• Chronic pain

• Usually lasts > 6 months ( some studies > 3 months) and even years.
• Interferes with functioning.

• Linked to conditions:
• Headache, arthritis, cancer, nerve pain, and back pain.

• Physical impact due to chronic pain

• Tense muscles, limited ability to move around and lack of energy.

• Emotional impact due chronic pain

• Depression, anger, anxiety.
• Fear of injury. This fear could limit your ability to leisure activities.
(Cleveland Clinic, 2020)
 Types of pain by pathophysiology
• A. Nociceptive (Latin nocere, Noci- = hurt / injury) pain
• Results from an injury or disease affecting somatic pain-sensitive structures such as skin, muscle, tendons, bone, and
joints.
• Activation of nociceptors by mechanical / thermal stimuli.

• 1. Cutaneous pain
• -originates in the skin or subcutaneous tissue
• e.g. paper cut causing a sharp pain and some burning

• 2. Deep somatic pain

• -arises from ligament, tendons, bones and nerves.
• e.g. ankle sprain

• 3. Visceral pain
• Stimulation of pain receptor in the abdominal cavity, thorax.
• Associated with nausea and vomiting.
• Frequently causes by ischemia, muscle spasm and distension of hollow organ.
• e.g. obstructed bowel (Kozier et al, 2004)
 Types of pain by pathophysiology
• B. Neuropathic pain
• Result of damage to the peripheral or central nervous systems.
• May not have a tissue damage.
• Long lasting.
• Peripheral neuropathic pain: DM neuropathy
• Central pain: Post stroke pain

• Other causes: Cancer, multiple sclerosis and amputation (phantom pain)

(Kozier et al, 2004)

Types of pain by experience
• Radiation pain
• Perceived at the source of the pain and extends to nearby tissues.
• e.g. cardiac pain be felt not only in the chest but also along left
shoulder and down the arm.

(Kozier et al, 2004)

Physiology of pain
Nociception
The peripheral nervous system included sensory neurons to detect tissue damage and to evoke the sensation of touch, heat,
cold, pain and pressure.
The receptors that transmit pain sensation are called nociceptors.

1. Transduction
Tissue injury triggers the release of biochemical mediators (e.g. prostaglandins) that sensitize nociceptors.

2. Transmission
Pain impulse travels from the peripheral nerve fibers to the spinal cord, then to the brain.

3. Perception
The client becomes conscious of the pain.
In Sensory cortex, which allows for different cognitive-behavioral strategies to be applied to reduce pain.

4. Modulation
Descending pathway. Brain send signals back down to the spinal cord.
Release endogenous opioids (e.g. endorphins), serotonin and non-epinephrine, which can inhibit the ascending painful impulse. (Sharma et al, 2018)
These substances are taken back by the body which limits their analgesic usefulness.
Clients with chronic pain may be prescribed tricyclic antidepressants, which inhibit the reuptake of non-epinephrine and
serotonin (serotonin-norepinephrine reuptake inhibitors).
(Kozier et al, 2004)
Common pain among elder person
• 1. Low back pain
• Low back pain (LBP) is a very common medical problem.
• There are many causes of LBP including injuries, diseases and degeneration. Poor posture accelerates degenerative changes of the spine.

• 2. Neck pain
• Common causes of neck pain are degeneration of the spine, poor posture and injury.

• 3. Frozen shoulder (肩周炎)

• Frozen shoulder is caused by inflammation of the soft tissue around the shoulder joint.
• It is more common in females and in people aged over 50.
• May be related to injury or overuse of the shoulder joint. Also, it may happen when movement of the shoulder is decreased, e.g. in people who
suffer from stroke.

• 4. Gout
• People who suffer from gouty arthritis are usually over 40 years old and male.
• Deposition of urate in tissues and raised uric acid level in blood.

• 5. Osteoarthritis of knee and hand

• Osteoarthritis is a disease caused by degeneration due to repetitive usage, decreased secretion of synovial fluid and thinning of cartilage.
• It is common among the elderly, and can affect the knee and finger joints. (EHS, 2022)
Barriers and challenge of pain management in older persons
• Older persons often underreports pain because of the fear of the loss of autonomy, require further treatment.

• Complexities of multiple conditions presenting with vague symptoms, making it difficult to determine the exact cause
of pain and appropriate treatment.

• Elderly clients have physical impairments, such as visual, or hearing loss or cognitive impairment which include
confusion, memory loss or dementia that interfere with clear communication (assessment, treatment adherence).

• Ageing increased threshold for sensation of pain and touch, possibly due to nerve conduction and neuron changes.
Change in nerve transmission may cause a variation in pain sensation.

• Decreased renal and liver functions in ageing that increase the risk of toxicity from pain medication (e.g. renal damage
form non-steroidal anti-inflammatory drugs, NSAID).

• Concerns of either the doctor or patient about the side effects of opioids, including respiratory depression, addiction
and falls, often create a barrier to indicated therapies.

• Concern of drug-drug interactions and polypharmacy.

(Kozier et al., 2004; Borsheski et al., 2014)
 Consequences of inadequate treatment of pain in
older persons
• Interferes with all aspects of the older person’s life, physical, psychological, social
and this can lead to poor quality of life.
• Interference with the activities of daily living (ADL) and diminished physical
functions, low mobility and limited independence.
• Sleep disturbance: Problems with sleep such as inability to initiate or maintain sleep.
• Mode changes and problems with the risk of anxiety, depression and social isolation.
• Even a tragedy.

(Buowari, 2021)
【雙屍命案】大窩口邨夫婦同受病魔煎熬 81歲夫77歲妻同墮樓亡

(Acknowledgement: 鄭禮賢 (2020, Apr 24) 【雙屍命案】大窩口邨夫婦同受病魔煎熬 81歲夫77歲妻同墮樓亡. Sky Post.

【雙屍命案】大窩口邨夫婦同受病魔煎熬 81歲夫77歲妻同墮樓亡 - 晴報 - 時事 - 要聞 - D200424 (ulifestyle.com.hk)
(Acknowledgement: 高聖雅 (2018, Feb 26). 【長照悲歌】老婦殺夫，「他要求我時，說死了比較快活」. 草根影響力新
視野. 【長照悲歌】老婦殺夫，「他要求我時，說死了比較快活」 | 草根影響力新視野 (grinews.com)
 Pain assessment tool
• OLDCART mnemonic • COLDSPA mnemonic
• O = Onset • C = Characteristic
• L = Location • O = Onset
• L = Location
• D = Duration (How long does it last)
• D = Duration
• C = Characteristic (Stabbing, dull, pin-pricking
cramping etc….) • S = Severity
• A = Aggravating factors • P = Pattern (what makes
it better / worse)
• R = Radiation • A = Associated factors
• T = Treatment (what was previously ineffective and (e.g. nausea, vomiting,
effective?) dizziness etc...

(Kozier et al, 2004)

Pain Assessment tool-Pain intensity or rating scales
• The single most important indicator of the existence and intensity of pain is
the client’s self reporting of pain.
• 1. 10-point pain intensity scale with word modifiers (verbal descriptive scale)
Pain Assessment tool-Pain intensity or rating scales
• 2. Wong-Baker FACES Rating Scale
• For elderly clients with impairments in cognition and communication.

Reflect pain quality

Assessment on precipitating & Alleviating factors
Precipitating factors
• Certain activities sometime precede pain.
• e.g. physical exertion may precede chest pain; abdominal pain after eating

• Environmental factors such as cold / heat / humidity can affect some types of pain. e.g.
generalized bone pain in a humid day.

• Emotional tension brings headache; fear can cause angina.

Alleviating factor
• Anything that can alleviate the pain
• e.g. rest, herbal teas, medications, heat / cold applications, distraction etc..
• Individualized.
(Kozier et al, 2004)
Assessment on the effect of Activities of Daily Living (ADL)
• How the pain has affected the following aspects of life:

• Sleep
• Appetite
• Concentration
• Work
• Home activities
• Leisure activities
• Emotional status

(Kozier et al, 2004)

Pain management-Nonpharmacologic
• 1. Cutaneous Stimulation
• Provide temporary pain relief
• 1.1 Massage
• -by increasing superficial circulation to
the area.
• -may use together with ointment and oil.

• .2 Acupressure
• -applying finger pressure to the points
used in acupuncture
(Kozier et al, 2004)
Pain management-Nonpharmacologic
• 1.3 Heat and Cold Applications
• A warm bath, hot / ice pads relieve pain and promote healing of
injured tissues.
Photo credit: 圖／IG@伊豆シャボテン動物公
園 by Yahoo Taiwan, 陳珮瑜
• Local effects of heat
• Vasodilation, and increase blood flow to the affected area,
bringing oxygen, nutrients and thus promote soft tissue healing.
• Relieve pain by promoting muscle relaxation, increasing
circulation and promoting psychologic relaxation and a feeling
of comfort.
• Often use for clients with joint stiffness, arthritis and low back
pain.

• Disadvantage: Increase permeability and allows extracellular

fluid to pass through the capillary walls and may result in edema
or an increase in preexisting edema.
Photo credit: Facebook 角落生物
(Kozier et al, 2004) Sumikko Gurashi Lovers すみっコぐらし
Pain management-Nonpharmacologic
• 1.3 Heat and Cold Applications
• Local effects of cold
• Opposite to heat therapy.
• Vasoconstriction, reduce blood flow to the affected area and thus
reduce the supply of oxygen and nutrients.
• Decreases pain by slowing nerve conduction rate, produces
numbness and increase pain threshold.
• Use for sports injuries (e.g. sprains, fracture) to reduce swelling and
bleeding.
(Kozier et al, 2004)
Pain management-Nonpharmacologic
• 2. Transcutaneous Electrical Nerve Stimulation (TENS)
• Trans- = across, through
• Applying low voltage electrical stimulation directly over
the pain areas, at an acupressure point and along
peripheral nerve areas.

• Activate large-diameter fibres that modulate the

transmission of the nociceptive impulse in the peripheral
and central nervous system (close the pain “gate”),
resulting in pain relief. [Gate Control Theory]

• Contraindicated for clients with pacemaker, arrhythmias

or in areas of skin breakdown.

(Kozier et al, 2004)

 Pain management-Nonpharmacologic
• 3. Cognitive-Behavioral intervention: Distraction
• Draws the person’s attention away from the pain and lessens the perception of pain.
• Visual: Watching TV, reading
• Auditory: Listening to music
• Tactile: Slow, rhythmic breathing
• Intellectual: Card games, crossword puzzles (Kozier et al, 2004)

• 3. Cognitive-Behavioral intervention: Mindfulness / Meditation

• Mindfulness meditation significantly attenuates pain through multiple, unique
mechanisms—an important consideration for the millions of chronic pain patients
seeking narcotic-free, self-facilitated pain therapy.
(Zeidan et al, 2016)
Summary of nonpharmacologic pain management -
Gate Control Theory

Acknowledgement: Alila Medical Media. (2022 Mar 01).Gate Control Theory of Pain, Animation. [Video]. YouTube.
https://www.youtube.com/watch?v=M-rL8XdHo6Q
Summary of pain management-Gate Control Theory
• Use of large-diameter nerve fibres
• Non-pain inputs “close the gate” to painful inputs, reducing pain.
• e.g. Back massage may stimulate impulses in LARGE nerves, which in turn close
the gate to back pain.
• Hot/cold packs
• TENS

• Increase the production of endorphins

• e.g. Pleasurable activities,
• Meditation
• Laughter
• Vigorous exercise
Pain management-Pharmacologic
• WHO Three-Step Ladder Approach
• 1st step. Mild pain: Non-opioid analgesics such as
*non-steroidal anti-inflammatory drugs (NSAID) or
paracetamol ± adjuvants.

• 2nd step. Moderate pain: Weak opioids (tramadol,

codeine) ± non-opioid ± adjuvants .

• 3rd step: Severe and persistent pain: Strong opioids

(morphine) ± non-opioid ± adjuvants.

• *NSAID e.g. Ibuprofen, Mefenamic acid, Diclofenac

(Voltaren)
• ** Adjuvants = also called co-analgesics including
tricyclic antidepressants (TCAs) such as
amitriptyline and serotonin-norepinephrine
reuptake inhibitors (SNRIs). (Photo credit: REBEL EM. CC BY-NC-ND 3.0)
(Anekar et al., 2022)
Tips for pain management in elders
• Focus on client’s control in dealing with the pain.
• Spend time with the client and listen carefully.
• Clarify misconception.
• Encourage independence whenever possible.

(Kozier et al, 2004)

Wrap up
• Types of pain in terms of duration: Acute pain and chronic pain
• Types of pain by pathophysiology: Nociceptive pain
• -Cutaneous, deep somatic and visceral pain
• Types of pain by pathophysiology: Neuropathic pain
• Radiation pain
• Physiology of pain: Transduction, transmission, perception and modulation
• Common pain among elder person: Low back pain, neck pain, frozen shoulder, gout and
osteoarthritis of knee and hand.
• Barrier and challenge: Complexities of multiple condition, age related changes,
polypharmacy etc….
• Pain assessment tool: OLDCART, COLDSPA, 10 point scale, Wong-Baker FACE Rating Scale
• Pain management-Nonpharmacologic: Massage, acupressure, heat/cold applications, TENS.
• Gate Control Theory of Pain
• Pain management-Pharmacologic : WHO Three-Step Ladder Approach
Reference
• Anekar, A. A. & Cascella, M. (2022). WHO Analgesic Ladder. StatPearls
Publishing LLC. https://www.ncbi.nlm.nih.gov/books/NBK554435/

• Borsheski, R. & Johnson, Q. L. (2014). Pain management in geriatric

population. Missouri Medicne, 111 (6): 508-511.

• Buowari, D. Y. (2021). Pain Management in Older Persons. In S. Amornyotin

(Ed.), Update in Geriatrics. IntechOpen. Pain Management in Older Persons
| IntechOpen

• Cleveland Clinic. (2020). Acute vs. Chronic Pain. Cleveland Clinic.

https://my.clevelandclinic.org/health/articles/12051-acute-vs-chronic-pain
Reference
• Elderly Health Service. (2022). Frozen shoulder. Department of Health, The Government of the Hong Kong
Special Administrative Region.
https://www.elderly.gov.hk/english/health_information/bones_and_joints/frozen.html

• Elderly Health Service. (2022). Gout. Department of Health, The Government of the Hong Kong Special
Administrative Region. https://www.elderly.gov.hk/english/health_information/bones_and_joints/gout.html

• Elderly Health Service. (2022). Low Back Pain. Department of Health, The Government of the Hong Kong
Special Administrative Region.
https://www.elderly.gov.hk/english/health_information/bones_and_joints/pain.html

• Elderly Health Service. (2022). Osteoarthritis of Hand. Department of Health, The Government of the Hong
Kong Special Administrative Region.
https://www.elderly.gov.hk/english/health_information/bones_and_joints/oa_hand.html

• Elderly Health Service. (2022). Osteoarthritis of Knee. Department of Health, The Government of the Hong
Kong Special Administrative Region.
https://www.elderly.gov.hk/english/health_information/bones_and_joints/osteoarthritisknee.html
Reference
• Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004). Fundamentals of Nursing:
Concept, process and practice. Pearson Education, Inc.

• Nelson, A., & Greene, K. (2021). Medical Terminology for Healthcare Professions.
University of West Florida Pressbooks.

• Sharma, R. S. & Das, G. (2018). What is the minimum knowledge of pain medicine
needed for other specialty? Journal on Recent Advances in Pain, 4(1): 32-35.

• Zeidan, F. & Vago, D. (2016). Mindfulness meditation-based pain relief: a

mechanistic account. Annals of the New York Academy of Sciences, 1373(1): 114-
127.