JAGS 50:S205–S224, 2002

© 2002 by the American Geriatrics Society

0002-8614/02/$15.00

The Management of Persistent Pain in Older Persons

AGS Panel on Persistent Pain in Older Persons

INTRODUCTION

Background and Significance

Pain is an unpleasant sensory and emotional experi-

ence.

1

Pain is a complex phenomenon derived from sen-

sory stimuli or neurologic injury and modified by individ-

ual memory, expectations, and emotions.

2

Pain is usually

associated with injury or a pathophysiologic process that

causes an uncomfortable experience and is usually de-

scribed in such terms. Although there are no objective bio-

logic markers of pain, an individual’s description and self-

report usually provides accurate, reliable, and sufficient

evidence for the presence and intensity of pain.

3

Persistent pain can be defined as a painful experience

that continues for a prolonged period of time that may or

may not be associated with a recognizable disease process.

The terms

persistent

and

chronic

are often used inter-

changeably in the medical literature. Unfortunately for

many elderly persons,

chronic

pain

has become a label as-

sociated with negative images and stereotypes often associ-

ated with longstanding psychiatric problems, futility in

treatment, malingering, or drug-seeking behavior. The

term

persistent pain

may foster a more positive attitude by

patients and professionals for the many effective treat-

ments that are available to help alleviate suffering.

4

The clinical manifestations of persistent pain are com-

monly multifactorial. Because of the complex interplay

among these factors across several domains (physiologic,

psychologic, and social), discriminating which factors are

most important for the purpose of treatment can be very

challenging. Further complicating this task is the fact that

pain expression and hence the importance of specific fac-

tors commonly vary, not only across individuals but also

over time in one individual.

Elderly persons have been defined by demographers,

insurers, and employers as those aged 65 years and over.

In healthcare discussions, the elderly persons often de-

scribed are those who are most frail, with health and dis-

ability problems typically encountered in the older popula-

tion. By age 75 many persons exhibit some frailty and

chronic illness. In the population above age 75, morbidity,

mortality, and social problems rise rapidly, resulting in

substantial strains on the healthcare system and societal

safety nets. This group represents the fastest growing seg-

ment of the total population.

5

The greatest challenges in

geriatric medicine are represented by the oldest, sickest,

and most frail patients with multiple medical problems

and few social supports. The guideline panel focused its

attention on this group as it prepared this update.

Persistent pain is common in older people.

6

A Louis

Harris telephone survey found that one in five older Amer-

icans (18%) are taking analgesic medications regularly

(several times a week or more), and 63% of those had

taken prescription pain medications for more than 6

months.

7

Older people are more likely to suffer from ar-

thritis, bone and joint disorders, back problems, and other

chronic conditions. This survey also found that 45% of

patients who take pain medications regularly had seen

three or more doctors for pain in the past 5 years, 79% of

whom were primary care physicians. Previous studies have

suggested that 25% to 50% of community-dwelling older

people suffer important pain problems.

6,8,9

Pain is also

common among nursing home residents.

10,11

It has been es-

timated that 45% to 80% of them have substantial pain

that is undertreated. Studies of both the community-dwell-

ing and nursing home populations have found that older

people commonly have several sources of pain, which is

not surprising, as older patients commonly have multiple

medical problems. A high prevalence of dementia, sensory

impairments, and disability in this population make as-

sessment and management more difficult.

The consequences of persistent pain among older peo-

ple are numerous. Depression, anxiety, decreased social-

ization, sleep disturbance, impaired ambulation, and in-

creased healthcare utilization and costs have all been

found to be associated with the presence of pain in older

people. Although less thoroughly described, many other

conditions are known to be worsened potentially by the

presence of pain, including gait disturbances, slow rehabil-

itation, and adverse effects from multiple drug prescrip-

tions.

12

Psychosocial factors affect and are affected by pain in

older patients. It has been shown that older adults with

good coping strategies have significantly lower pain and

This guideline was developed and written under the auspices of the Ameri-

can Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons and

approved by the AGS Board of Directors on April 8, 2002.

Address correspondence to Elvy Ickowicz, MPH, Manager, Professional

Education and Special Projects, American Geriatrics Society, 350 Fifth

Avenue, Suite 801, New York, NY, 10118. email: eickowicz@

americangeriatrics.org