Need to Evaluate Pain Management in Elderly Population Grows

This article was originally published by MD Magazine.

As more of the US population ages, a focus on the impact that pain management strategies have on the elderly will become more and more vital, and an investigative team from the University of Texas at Arlington (UTA) are focusing on those challenges.

Led by Robert Gatchel, PhD, the UTA distinguished professor of psychology, the Nancy P. and John G. Penson endowed professor of clinical health psychology, and director of UTA’s Center of Excellence in Health & Chronic Illness, he and Kelley Bevers, BS, a PhD candidate, analyzed the challenges of using opioids, antidepressants, anti-inflammatories, and topical or injectable agents to treat pain in the elderly.

“Pain is prevalent and often under-treated among older adults,” Gatchel said in a statement. “With 20% of Americans expected to be 65 or older by 2030, the development of new and effective pain management strategies is a necessity, especially given that 75 percent of people in this age group have two or more chronic conditions such as heart disease, arthritis or diabetes, which complicate the taking of pain medications.”

Gatchel and Bevers first analyzed opioids, noting that while they are efficacious in treating pain, they present concerns “such as their high abuse and dependency potential, sedative effects, and risk of drug interactions” and are 1 of the more abused drug classes in the US. More specifically, they create some issues specific to the older population.

"The side effects of opioids, such as nausea and dizziness, can lead to an increased risk and rate of falls and subsequent injury, particularly among the older population," Gatchel said. "Older adults are also more prone to physical side effects from these drugs, such as liver and kidney problems, and need both careful evaluation and routine testing of organ function for follow-up care."

Other options for treating pain consist of some antidepressants, such as tricyclics like amitriptyline and clomipramine, have all shown success in pain management. However, while shown to be effective, they can carry concerns for older adults, as the presence of comorbidities that impact cognition and motor function can impact the adherence and consistency of medication consumption.

“This can be particularly troublesome when on a regimen with antidepressants because a sudden cessation can lead to complications such as suicidal thoughts or behaviors, depression, or mood imbalances,” Gatchel and Bevers wrote. Shifts in mood or behavior can be dangerous for the elderly due to concerns about interactions with other medications as well, such as steroids or hormonal supplements, which can exacerbate symptoms of depression.

Non-steroidal anti-inflammatories (NSAIDs), have become more widely used in place of opioids in multiple settings of medicine because of their less addictive properties but can have interaction issues with gastrointestinal toxicity. This can be countered with gastro-protective therapies in conjunction with the NSAIDs, according to Gatchel.

With that in mind, only about 40% of older patients with gastrointestinal conditions are prescribed both NSAIDs and gastro-protective drugs.

Gatchel and Bevers also explored the options of topical creams and injectable agents but found that while these can be feasible for elderly patients that cannot take oral medications, they are often not as efficacious as other options. “Topical creams and patches can be effective for localized pain presenting in areas near the body surface, but may not be powerful enough to penetrate the body to treat certain pain conditions. Topical agents also require reapplication and may wear-off or cause irritation,” they wrote.

Although they did note that transdermal patches, which can allow for the administration of more powerful pain relief therapies, such as morphine, can be effective and allow for a slower, steady release and absorption. In any case, a complete history of medical treatment that includes current medications would be essential providing pharmacotherapy to the elderly, Gatchel and Bevers wrote.

“Each major medication group, such as opioids, NSAIDs, and antidepressants, present advantages and complications to pain management, and must complement comorbidities and other medicinal needs,” they wrote. “Older adults must also undergo thorough screening in order to assess organ function and weight changes.”

By 2050, an anticipated 89 million Americans are expected to be aged 65 years or older, more than double the total of 40 million today, according to data from the Population Reference Bureau. Additionally, the oldest of the older population—defined as those 85 years and older—will consist of 19 million, increasing to 20% of the total population over age 65.

“Pain management in older adults is a complex and multi-faceted issue,” Gatchel said. “Older adults face unique challenges that can further complicate general concerns, so complete medical histories including current medications are essential for effective and safe pharmacotherapy. Each major medication group presents advantages and complications to pain management and must complement other medicinal needs, so thorough screening is essential.”

The paper, “Anesthesia and pain management in older adults,” was published in EC Anesthesia's 2017 special issue.