Pain and Pain Management

  • David J. Hewitt
  • Kathleen M. Foley


The treatment of pain in the elderly patient presents many challenges: their pain syndromes are often due to chronic diseases that are not curable; the metabolic and pharmacodynamic changes that accompany aging complicate the prescribing of analgesics; cognitive dysfunction confounds pain assessment; functional ability may be impaired; and psychosocial issues often need to be addressed. In short, further data are required to improve pain treatment in this population. The appropriate management of pain in the elderly is based on general principles of assessment, pharmacotherapy, and use of anesthetic, neurosurgical, and cognitive-behavioral interventions. The strategy employed includes a careful history and physical examination to define the symptom complex, the pain pathophysiology and etiology, and to pursue a diagnostic and therapeutic plan. Often, the pain can be treated by directing attention to the underlying cause, for example, replacing a fractured hip. In other instances either the cause cannot be determined or it is not amenable to medical or surgical intervention and pain management consists of treating the pain complaint with analgesics alone.


Chronic Pain Neuropathic Pain Pain Management Pain Syndrome Cancer Pain 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Crook J, Rideout E, Browne G. The prevalence of pain complaints in a general population. Pain. 1984; 18 (3): 299–314.PubMedCrossRefGoogle Scholar
  2. 2.
    Ferrell BA, Ferrell BR. Principles of pain management in older people. Compr Ther. 1991; 17 (8): 53–58.PubMedGoogle Scholar
  3. 3.
    Sorkin BA, Rudy TE, Hanlon RB, et al. Chronic pain in old and young patients: differences appear less important than similarities. J Gerontol. 1990; 45 (2): 64–68.CrossRefGoogle Scholar
  4. 4.
    Thomas MR, Roy R. Age and pain: a comparative study of the younger and older elderly. J Pain Manage. 1988; 1: 174–179.Google Scholar
  5. 5.
    Moss MS, Lawton, MP, Glicksman A. The role of pain in the last year of life of older persons. J Gerontol. 1991; 46 (2): 51–57.CrossRefGoogle Scholar
  6. 6.
    Sternbach RA. Survey of pain in the United States: The Nuprin Pain Report. J Clin Pain. 1986; 2: 49.CrossRefGoogle Scholar
  7. 7.
    Lavsky-Shulan M, Wallace RB, Kohout FJ, et al. Prevalence and functional correlates of low back pain in the elderly: the Iowa 65+ Rural Health Study. J Am Geriatr Soc. 1985; 33: 23–28.PubMedGoogle Scholar
  8. 8.
    Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home./Am Geriatr Soc. 1990; 38: 409–414.Google Scholar
  9. 9.
    Roy R, Michael TA. Survey of chronic pain in an elderly population. Can Fam Physician. 1986; 32: 513.PubMedGoogle Scholar
  10. 10.
    Roberts HC, Eastood H. Pain and its control in patients with fractures of the femoral neck while awaiting surgery. Injury. 1994; 25 (4): 237–239.PubMedCrossRefGoogle Scholar
  11. 11.
    Johansson C, Mellstrom D, Rosengren K, et al. Prevalence of vertebral fractures in 85-year-olds. Radiographic examination of 462 subjects. Acta Orthop Scand. 1993; 64 (l): 25–27.PubMedGoogle Scholar
  12. 12.
    Bliss MR, Schofield M. A pilot leg ulcer clinic in a geriatric day hospital. Age Ageing. 1993; 22 (4): 279–284.PubMedCrossRefGoogle Scholar
  13. 13.
    Flett R, Harcourt B, Alpass F. Psychosocial aspects of chronic lower leg ulceration in the elderly. West J Nurs Res. 1994; 16 (2): 183–192.PubMedCrossRefGoogle Scholar
  14. 14.
    Lindholm C, Bjellerup M, Christensen OB, et al. Quality of life in chronic leg ulcer patients. An assessment according to the Nottingham Health Profile. Acta Derm Venereol. 1993; 73 (6): 440–443.PubMedGoogle Scholar
  15. 15.
    Ciocon JO, Fernandez BB, Ciocon DG. Leg edema: clinical clues to the differential diagnosis. Geriatrics. 1993; 48 (5): 34–40.PubMedGoogle Scholar
  16. 16.
    Kay L. Prevalence, incidence and prognosis of gastrointestinal symptoms in a random sample of an elderly population. Age Ageing. 1994; 23 (2): 146–149.PubMedCrossRefGoogle Scholar
  17. 17.
    Foley KM. Pain syndromes in patients with cancer. Med Clin North Am. 1987; 71 (2): 169–184.PubMedGoogle Scholar
  18. 18. Mor V. Hospice Care Systems: Structure Process Costs and Outcomes. New York: Springer; 1987.Google Scholar
  19. 19.
    Morris J, Mor V, Goldberg R, et al. The effect of treatment setting and patient characteristics on pain in terminal cancer patients: a report from the National Hospice Study. J Chron Dis. 1986; 39 (l): 27–35.PubMedCrossRefGoogle Scholar
  20. 20.
    Morris J, Suissa S, Sherwood S, et al. Last days: a study of the quality of life of terminally ill cancer patients. J Chron Dis. 1986; 39 (l): 47–62.PubMedCrossRefGoogle Scholar
  21. 21.
    McCormack A, Hunter-Smith D, Piotrowski ZH, et al. Analgesic use in home hospice cancer patients. J Fam Pract. 1992; 34 (2): 160–164.PubMedGoogle Scholar
  22. 22.
    Magni D, et al. Pain as a symptom in elderly depressed patients. Eur Arch Psychiatr Neurol Sci. 1985; 235: 143.CrossRefGoogle Scholar
  23. 23.
    Mcintosh IB. Psychological aspects influence the threshold of pain. Geriatr Med. 1990; 20: 37–41.Google Scholar
  24. 24.
    Kennedy GJ, Kelman HR, et al. Hierarchy of characteristics associated with depressive symptoms in an urban elderly sample. Am J Psychiatry. 1989; 146: 220–225.PubMedGoogle Scholar
  25. 25.
    Parmelee PA, Katz IR, Lawton MP. The relation of pain to depression among institutionalized aged. J Gerontol. 1991; 46: 15–21.CrossRefGoogle Scholar
  26. 26.
    Keefe FJ, Williams DA. A comparison of coping strategies in chronic pain patients in different age groups./Gerontol. 1990; 45 (4): 161–165.Google Scholar
  27. 27.
    Canellas M, Bosch F, Bassols A, et al. The prevalence of pain in hospitalized patients. Med Clin. 1993; 101 (2): 51–54.Google Scholar
  28. 28.
    Greenlee KK. Pain and analgesia: considerations for the elderly in critical care. AACN Clin Issues Crit Care Nurs. 1991; 2: 720–728.PubMedGoogle Scholar
  29. 29.
    Hall-Lord ML, Larsson G, Bostrom I. Elderly patients’ experiences of pain and distress in intensive care: a grounded theory study. Intensive Crit Care Nurs. 1994; 10 (2): 133–141.PubMedCrossRefGoogle Scholar
  30. 30.
    Clement DG, Retchin SM, Brown RS, et al. Access and outcomes of elderly patients enrolled in managed care. JAMA. 1994; 271: 1487–1492.PubMedCrossRefGoogle Scholar
  31. 31.
    Bonica J. Pain research and therapy: past and current status and future needs. In: NG LKY, Bonica JJ, eds. Proceedings of the National Conference on Pain, Discomfort and Humanitarian Care. New York: Elsivier; 1980: 1–47.Google Scholar
  32. 32.
    Cohen F. Postsurgical pain relief: patients’ status and nurses’ medication choices. Pain. 1980; 9: 265–274.PubMedCrossRefGoogle Scholar
  33. 33.
    Brockopp DY, Warden S, Colclough G, et al. Nursing knowledge: acute postoperative pain management in the elderly. J Gerontol Nurs. 1993; 19 (ll): 31–37.PubMedGoogle Scholar
  34. 34.
    McCaffery M, Ferrell B, O’Neill-Page E, et al. Nurses’ knowledge of opioid analgesic drugs and psychological dependence. Cancer Nursing. 1990; 13 (l): 21–27.PubMedCrossRefGoogle Scholar
  35. 35.
    Williams MA, Campbell EB, Raynor W Jr, et al. Predictors of acute confusional states in hospitalized elderly patients. Res Nurs Health. 1985; 8 (1): 31–40.PubMedCrossRefGoogle Scholar
  36. 36.
    Williams-Russo P, Urquhart BL, Sharrock NE, et al. Post-operative delirium: predictors and prognosis in elderly orthopedic patients [see comments]. J Am Geriatr Soc. 1992; 40 (8): 759–767.PubMedGoogle Scholar
  37. 37.
    Bowen DM, Davison AN. Biochemical changes in the normal aging brain and in dementia. In: Issacs B, ed. Recent Advances in Geriatric Medicine. Edinburgh: Churchill Livingstone; 1978.Google Scholar
  38. 38.
    Parmelee PA, Smith B, Katz IR. Pain complaints and cognitive status among elderly institution residents. J Am Geriatr Soc. 1993; 41: 517–522.PubMedGoogle Scholar
  39. 39.
    Portenoy RK, Kanner RM. Patterns of analgesic prescription and consumption in a university-affiliated community hospital. Arch Intern Med. 1985; 145: 439.PubMedCrossRefGoogle Scholar
  40. 40.
    Goldberg RJ, et al. Analgesic use in terminal cancer patients: report for the National Hospice Study. J Chron Dis. 1986; 39: 37.PubMedCrossRefGoogle Scholar
  41. 41.
    Faherty BS, Grier MR. Analgesic medication for elderly people post-surgery. Nurs Res. 1984; 33: 369–372.PubMedCrossRefGoogle Scholar
  42. 42.
    Harkins SW, Price DD, Martelli M. Effects of age on pain perception: thermonociception. J Gerontol. 1986; 41 (1): 58–63.PubMedCrossRefGoogle Scholar
  43. 43.
    Thomson FJ, Masson EA, Boulton AJ. The clinical diagnosis of sensory neuropathy in elderly people. Diabet Med. 1993; 10: 843–846.PubMedCrossRefGoogle Scholar
  44. 44.
    Kaiko RF, Wallenstein SL, Rogers AG, et al. Narcotics in the elderly. Med Clin North Am. 1982; 66: 1079–1089.PubMedGoogle Scholar
  45. 45.
    Reidenberg MM. Drugs in the elderly. Med Clin North Am. 1982; 66: 1073–1078.PubMedGoogle Scholar
  46. 46.
    Scott JC, Stanski DR. Decreased fentanyl and alfentanil dose requirements with age. A simultaneous pharmacokinetic and pharmacodynamic evaluation. J Pharmacol Exp Ther. 1987; 240 (1): 159–166.PubMedGoogle Scholar
  47. 47.
    Sengstaken EA, King SA. The problems of pain and its detection among geriatric nursing home residents./Am Geriatr Soc. 1993; 41: 541–544.Google Scholar
  48. 48.
    Bonica J J. The Management of Pain. 2nd ed. Philadelphia: Lea & Febiger; 1990.Google Scholar
  49. 49.
    Wall PD, Melzack R. Textbook of Pain. Edinburgh: Churchill-Livingstone; 1994.Google Scholar
  50. 50.
    IASP Subcommittee on Taxonomy Pain Terms. A list with definitions and notes on usage. Pain. 1979; 6: 249.Google Scholar
  51. 51.
    Herr KA, Mobily PR, Smith C. Depression and the experience of chronic back pain: a study of related variables and age differences. Clin J Pain. 1993; 9 (2): 104–114.PubMedCrossRefGoogle Scholar
  52. 52.
    Galer BS, Portenoy RK. Acute herpetic and postherpetic neuralgia: clinical features and management. Mt Sinai J Med. 1991; 58 (3): 257–266.PubMedGoogle Scholar
  53. 53.
    Portenoy RK, Farkash A. Acute herpetic and postherpetic neuralgia: clinical review and current management. Ann Neurol. 1987; 20: 651.CrossRefGoogle Scholar
  54. 54.
    Portenoy RK, Hagen NA. Breakthrough pain: definition and management. Oncology. 1989; 3 (suppl 8): 25–29.PubMedGoogle Scholar
  55. 55.
    Portenoy RK, Farkash A. Optimal control of non-malignant pain in the elderly. Geriatrics. 1988; 43 (5): 29.PubMedGoogle Scholar
  56. 56.
    Herr KA, Mobily PR. Chronic pain and depression. J Psychosoc Nurs Ment Health Serv. 1992; 30 (9): 7–12.PubMedGoogle Scholar
  57. 57.
    Kellgren JG. On the distribution of pain arising from deep somatic structures with charts of segmental pain areas. Clin Sci. 1939; 4: 35–46.Google Scholar
  58. 58.
    Foltstein MF, Foltstein SE, McHugh PR. Mini-Mental State: a practical method of grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12: 189–198.CrossRefGoogle Scholar
  59. 59.
    Pfieffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975; 23 (10): 433–441.Google Scholar
  60. 60.
    Melzack R, Wall P. The Challenge of Pain. New York: Basic Books; 1983.Google Scholar
  61. 61.
    Keefe F, Bradley L. Behavioral and psychological approaches to the assessment and treatment of chronic pain. Gen Hosp Psychiatry. 1984; 6 (l): 49–54.PubMedCrossRefGoogle Scholar
  62. 62.
    Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975; 1: 277–299.PubMedCrossRefGoogle Scholar
  63. 63.
    Melzack R. The short-form McGill Pain Questionnaire. Pain. 1987; 30: 191–197.PubMedCrossRefGoogle Scholar
  64. 64.
    Herr KA, Mobily PR. Pain assessment in the elderly. Clinical considerations. J Gerontol Nurs. 1991; 17 (4): 12–19.PubMedGoogle Scholar
  65. 65.
    Herr KA, Mobily PR. Comparison of selected pain assessment tools for use with the elderly. Appl Nurs Res. 1993; 6 (l): 39–46.PubMedCrossRefGoogle Scholar
  66. 66.
    Barsky AJ, Frank CB, Cleary PD, et al. The relation between hypochondriasis and age. Am J Psychiatry. 1991; 148: 923–928.PubMedGoogle Scholar
  67. 67.
    Middaugh SJ, Levin RB, Kee WG, et al. Chronic pain: its treatment in geriatric and younger patients. Arch Phys Med Rehabil. 1988; 69: 1021–1026.PubMedGoogle Scholar
  68. 68.
    Cutler RB, Fishbain DA, Rosomoff RS, et al. Outcomes in treatment of pain in geriatric and younger age groups. Arch Phys Med Rehabil. 1994; 75 (4): 457–464.PubMedCrossRefGoogle Scholar
  69. 69.
    Cohen JL. Pharmacokinetic changes in aging. Am J Med. 1886; 80 (5A): 31–38.CrossRefGoogle Scholar
  70. 70.
    Morgan J, Furst DE. Implications of drug therapy in the elderly. Clin Rheum Dis. 1986; 12: 227–244.PubMedGoogle Scholar
  71. 71.
    Geokas MC, Haverback BJ. The aging gastrointestinal tract. Am J Surg. 1969; 117: 881–892.PubMedCrossRefGoogle Scholar
  72. 72.
    Goldberg PB, Roberts J. Pharmacologic basis for developing rational drug regimens for elderly patients. Med Clin North Am. 1983; 67: 315–331.PubMedGoogle Scholar
  73. 73.
    Bender AD. The effect of increased age on the distribution of peripheral blood flow in man. J Am Geriatr Soc. 1965; 13: 192.PubMedGoogle Scholar
  74. 74.
    Bender AD. Pharmacodynamic principles of drug therapy in the aged. J Am Geriatr Soc. 1974; 22 (7): 296–303.PubMedGoogle Scholar
  75. 75.
    Rafsky HA, Newman B. Liver function test in the aged. The serum cholesterol partition, bromsulphalein, cephalin flocculation and oral and intravenous hippuric acid test. Am J Digest Dis. 1965; 10: 66.CrossRefGoogle Scholar
  76. 76.
    Schlegel SE, Paulus H. Non-steroidal and analgesic therapy in the elderly. Clin Rheum Dis. 1986; 12: 245.PubMedGoogle Scholar
  77. 77.
    Ciabattoni G, Cinotti G, Pierucci A, et al. Effects of sulindac and ibuprofen in patients with chronic glomerular disease: evidence for the dependence of renal function on prostacyclin. N Engl J Med. 1984; 310: 279–283.PubMedCrossRefGoogle Scholar
  78. 78.
    Whelton A, Stout R, Spilman P, et al. Renal effects of ibuprofen, piroxicam, and sulindac in patientsGoogle Scholar
  79. 79.
    with asymptomatic renal failure: a prospective, randomized, crossover comparison. Ann Intern Med. 1990; 112:568–576.Google Scholar
  80. 80.
    Belleville JW, et al. Influence of age on pain relief from analgesics. JAMA. 1971; 217: 1835.CrossRefGoogle Scholar
  81. 81.
    Kaiko RF. Age and morphine analgesia in cancer patients with postoperative pain. Clin Pharmacol Ther. 1980; 28: 823–826.PubMedCrossRefGoogle Scholar
  82. 82.
    Helmers H, Van Peer A, Woestenborghs R, et al. Alfentanil kinetics in the elderly. Clin Pharmacol Ther. 1984; 36 (2): 239–243.PubMedCrossRefGoogle Scholar
  83. 83.
    Simons LA, Tett S, Simons J, et al. Multiple medication use in the elderly. Use of prescription and nonprescription drugs in an Australian community setting. MedJAust. 1992; 157 (4): 242–246.Google Scholar
  84. 84.
    Forbes JA, Butterworth GA, Burchfield WH, et al. Evaluation of ketorolac, aspirin, and an acetaminophen-codeine combination in postoperative oral surgery pain. Pharmacotherapy. 1990; 9 (5): 322–330.Google Scholar
  85. 85.
    Perneger TV, Whelton PK, Klag MJ. Risk of kidney failure associated with the use of acetaminophen, aspirin, and nonsteroidal antiinflammatory drugs [see comments]. N Engl J Med. 1994; 331 (25): 1675–1679.PubMedCrossRefGoogle Scholar
  86. 86.
    Sager DS, Bennett RM. Individualizing the risk/benefit ratio of NSAIDs in older patients. Geriatrics. 1992; 47 (8): 24–31.PubMedGoogle Scholar
  87. 87.
    Brooks PM, Day RO. Nonsteroidal antiinflammatory drugs—differences and similarities [published erratum appears in N Engl J Med. 1991;325:747] [see comments]. N Engl J Med. 1991; 324: 1716–1725.PubMedCrossRefGoogle Scholar
  88. 88.
    Graham D, White RH, Moreland LW, et al. Duodenal and gastric ulcer prevention with Misoprostol in arthritis patients taking NSAIDS. Ann Intern Med. 1993; 119: 257.PubMedGoogle Scholar
  89. 89.
    Ferrer-Brechner T, Ganz P. Combination therapy with ibuprofen and methadone for chronic cancer pain. Am J Med. 1984; 77 (lA): 78–83.PubMedCrossRefGoogle Scholar
  90. 90.
    Houde RW, et al. Evaluation of analgesics in patients with cancer pain. In: Lasagna L, ed. International Encyclopedia of Pharmacology and Therapeutics. Vol. 1. New York: Pergamon; 1966: 59.Google Scholar
  91. 91.
    Beaver WT, Feise G. Comparison of the analgesic effects of morphine, hydroxyzine, and their combination in patients with postoperative pain. In: Bonica JJ, ed. Advances in Pain Research and Therapy. Vol. 1. New York: Raven Press; 1976: 553–557.Google Scholar
  92. 92.
    Forrest W Jr, Brown B Jr, Brown CR, et al. Dextroamphetamine with morphine for the treatment of postoperative pain. N Engl J Med. 1977; 296: 712–715.PubMedCrossRefGoogle Scholar
  93. 93.
    Bruera E, Brenneis C, Paterson AH, et al. Narcotics plus methylphenidate (Ritalin) for advanced cancer pain. Am J Nurs. 1988; 88: 1555–1556.PubMedGoogle Scholar
  94. 94.
    Bruera E, Brenneis C, Paterson AH, et al. Use of methylphenidate as an adjuvant to narcotic analgesics in patients with advanced cancer. J Pain Symptom Manage. 1989; 4 (l): 3–6.PubMedCrossRefGoogle Scholar
  95. 95.
    Bruera E, Chadwick S, Brenneis C, et al. Methylphenidate associated with narcotics for the treatment of cancer pain. Cancer Treat Rep. 1987; 71 (l): 67–70.PubMedGoogle Scholar
  96. 96.
    Foley KM, Macaluso C. Adjuvant analgesic drugs in cancer pain management. In: Aronoff GM, ed. Evaluation and Treatment of Chronic Pain. 2nd ed. Baltimore: Williams & Wilkins; 1992: 340.Google Scholar
  97. 97.
    Watson CRN, et al. Amitriptyline vs placebo in postherpetic neuralgia. Neurology. 1982; 32: 671.PubMedCrossRefGoogle Scholar
  98. 98.
    Getto CJ, Sorkness CA, Howell T. Antidepressants and chronic nonmalignant pain: a review. J Pain Symptom Manage. 1987; 2: 9–18.PubMedCrossRefGoogle Scholar
  99. 99.
    Weinberg DS, et al. Sublingual absorption of selected opioid analgesics. Clin Pharmacol Ther. 1988; 44: 335.PubMedCrossRefGoogle Scholar
  100. 100.
    Coyle N. Continuous subcutaneous infusions of opiates in cancer patients with pain. Oncol Nurs Forum. 1986; 13: 53.PubMedGoogle Scholar
  101. 101.
    Portenoy RK, et al. Intravenous infusions of opioids in cancer pain: clinical review and guidelines for use. Cancer- Treat Rep. 1986; 70: 575.PubMedGoogle Scholar
  102. 102.
    Cousins MJ, Mather LE. Intrathecal and epidural administration of opioids. Anesthesiology. 1984; 61 (3): 276–310.PubMedCrossRefGoogle Scholar
  103. 103.
    Coyle N, Foley KM. The use of multiple routes of opioid drug administration in an advanced cancer patient. J Pain Symptom Manage. 1993; 8 (4): 234–237.PubMedCrossRefGoogle Scholar
  104. 104.
    Galer BS, Coyle N, Pasternak GW, et al. Individual variability in the response to different opioids: report of five cases. Pain. 1992; 49: 87–91.PubMedCrossRefGoogle Scholar
  105. 105.
    Cherny N, Chang V, Ingham J, et al. [Abstract] The prevalance and outcomes of sequential trials of opioid analgesics in management of cancer pain. Presented at the 12th Annual Scientific meeting of the American Pain Society, Orlando, FL, 1993.Google Scholar
  106. 106.
    Bruera E, Schoeller T, Montejo G. Organic hallucinosis in patients receiving high doses of opiates for cancer pain. Pain. 1992; 48: 397–399.PubMedCrossRefGoogle Scholar
  107. 107.
    Bruera E, Macmillan K, Hanson J, et al. The cognitive effects of the administration of narcotic analgesics in patients with cancer pain. Pain. 1989; 39: 13–16.PubMedCrossRefGoogle Scholar
  108. 108.
    Porter J, Jick H. Addiction rare in patients treated with narcotics [letter]. N Engl J Med. 1980; 302 (2): 123.PubMedGoogle Scholar
  109. 109.
    Foley KM. Clinical tolerance to opioids. In: Basbaum A, Besson JM, eds. Towards a New Pharmacotherapy of Pain. Chichester: Wiley; 1991: 181.Google Scholar
  110. 110.
    Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: Williams and Wilkins; 1983.Google Scholar
  111. 111.
    Nashold B. Current status of the DREZ operation. Neurosurgery. 1984; 15: 942–944.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 1997

Authors and Affiliations

  • David J. Hewitt
  • Kathleen M. Foley

There are no affiliations available

Personalised recommendations