Introduction

Two years has passed since the declaration of 2006-2007 the years of pain control in elderly patients. Many lights were shed on the question of pain control in that group of population

Many modalities of therapy has been developed and many misconnects were put aside. In this article the author review briefly the main issues discussed in recent Symposium in Riyadh in order to take the issue further in wider scope of readers

Pain management in the elderly patients

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Some pain is generated from within the nervous system itself. Such neuropathic pain (damage to nerve) can present in trigeminal neuralgia, post stroke pain, post hepatic neuralgia and in diabetic neuropathies.

Nociceptive pain (stimulation of pain receptors) can present in post-operative period, post trauma, rheumatoid or osteoarthritis, myofascial pain syndrome, ischemic disorders, cancer and in chronic back pain.

Pain is common in old age, but it is not a normal consequence of ageing, pathology is always involved. There are many morphological and neurochemical changes in the elderly brain that could effect pain perception.

Electrophysiological studies show slower central processing of incoming noxious stimuli and reduced cortical activation with increasing age. There is no evidence that ageing per se changes pain intensity or immediate unpleasantness of pain.

Older people do report less emotional distress and illness and pain. This can lead to miscommunication between the patient and medical team, such that underlying pathology may be masked by behavioral disturbances.

There is no evidence that age alone leads to a difference in a person's ability to cope.

Pain is often under-treated and under-reported in older adults.

There are a number of assessment tools available to assess pain but the Verbal Descriptor Scale (VDS) was shown by Herr and Mobily 1993 to be preferred by older adults (Herr & Mobily 1993).

This scale rates from pain to severe pain to very severe pain up to worst possible pain.

Educating older adults about pain and methods to relieve pain has been identified as a key intervention in developing a plan of core that will be successful for the individual (Herr, 2002).

The American Genatric Society (2006) reported that analgesia may be used safely and effectively in older adults. They published the following key recommendations for practitioners prescribing analgesics for chronic pain:

1. Use least invasive route of administration

2. Use short acting analgesic drugs for episodic pain

3. Use round the clock not p.m. administration

4. Start low and go slow

5. Anticipate, prevent and treat adverse effects

Drugs to be specifically avoided in elderly include:

1. Meperidine – because of toxic effect of its metabolite norm

2. Methadone – long half life makes it a risk to use in elderly

3. Propoxyphene – has an increased chance of dependence

4. Pentazoan – poor analgesic, causes delirium and agitation

Non medication treatment (non-pharmacological treatment) includes:

1. Music therapy

2. Relaxation technique

3. Massage therapy

4. Soft lighting, decreased noise

5. Worm or cold packs

6. Repositioning exercises

7. Aroma therapy such as lavender to calm the body

8. Emotional and spiritual support

9. Psychotherapy

10. Immobilization

11. Transcutaneous electrical nerve stimulation

12. Acupuncture

13. Cutaneous stimulation

14. Hypnosis

Conclusion

Analgesics are the most common type of pain management. Both prescription and non-prescription medications can be used to treat pain.

Because elderly are more sensitive to the effect of medications (caused by decreased hepatic blood flow and decreased renal blood flow – slower clearance) and more likely to be on multiple medications and have complicated drug regimens. Careful consideration and monitoring of drug therapies for pain management is essential.

In addition, non-drug therapies should be used in conjunction with pharmacologic treatment when possible.