PAIN MANAGEMENT

Pain is an unpleasant sensation induced by a noxious stimulus, and is transmitted along special nerve pathways to the brain. Many older adults state that it is the experience of chronic pain, more than anything else, that alters their individual sense of themselves, making them finally "feel old." While many age-related conditions give rise to pain, the experience of pain itself is nevertheless not part of normal aging. Indeed, there is evidence that the thresholds for some types of pain appear to be increased in older adults (i.e., they feel some types of pain less readily than younger adults).

Pain is one modality of the sensory system (others are the experience of light and deep touch, temperature, and vibration sense). Pain is a useful sensation that warns the body of injury, but chronic pain can be both physically wearing and psychologically debilitating. Pain sensation is perceived as a consequence of pain receptors (nocioceptors) located throughout the body. Through peripheral nerve pathways, pain impulses travel to the spinal cord and thence to the brain. In the brain several structures participate in the transmission of the pain impulses and in their appreciation in consciousness. Some part of the appreciation of pain appears to be susceptible to conscious manipulation, but many of the pain pathways are mediated as reflexes (i.e., they are not subject to conscious control).

Pain receptors function differently in different parts of the body, as reflected, in part, by differences in the ability to distinguish the source of pain. For example, pain in the hand can be localized very precisely to within millimeters of its source, whereas pain in the heart, as in a heart attack, can be experienced in the chest, arm, or jaw. Indeed, in some elderly people who have acute pain, it can be manifested as delirium, and not as any specific complaint of pain.

To understand such a broad class of sensations, pain can be approached in a number of ways. One way is to contrast acute pain with chronic pain. The latter is not just acute pain that has persisted, but pain that impacts on emotions and on an individual's sense of well-being, often in such a way that each feeds back negatively on the other.

Pain is traditionally divided by its likely source, as being somatic (e.g., pain in joints, muscles, skin), visceral (e.g., from irritation, stretching, compression, or infiltration of organs such as the heart, liver, or lungs), or neuropathic (i.e., pain arising from the peripheral nerves, the spinal cord, or certain parts of the brain, especially the thalamus). Of all the types of chronic pain, neuropathic pain can be the most difficult to treat with traditional analgesic medications. Nontraditional approaches seem to offer some benefit in all types of pain, although they apparently need to be used with regularity to achieve their greatest impact.

Pain is a particularly important problem among older adults who undergo surgery, and the discipline of anesthesia has developed many strategies for pain relief in older adults. Pain control is also an important focus of palliative care. In community-dwelling older adults who are physically frail, it appears that pain is common and its control is often inadequate. Pain is linked to the progression of disability in older adults who are functionally impaired.

The principles of pain management in older adults are similar to pain management principles in general. The lowest effective doses should be employed. Drugs for chronic pain should be given proactively on a regular basis, and not in reaction to pain. Even when patients are in the hospital, they should have a role in determining how often pain medication is given, and at what dose. Where chronic pain is poorly controlled by a single medication, combinations of medications should be used, in conjunction with nonpharmacologic approaches. Such approaches can include massage, acupuncture, and therapeutic use of heat and cold, as well as techniques such as yoga, visualization, self-hypnosis, and biofeed-back.

Pain is experienced as even more noxious when it is accompanied by emotional upset (such as fear or anger), and especially when it is accompanied by a sense of lack of control. In consequence, counseling to provide insight into these factors, as well as techniques to help patients regain control, can be particularly beneficial. For this, the setting of precise goals can be especially useful. Specifying a range of goals, from being always pain free to something short of that, allows progress to be measured and the results of intermediate states to be documented. This in turn allows more precise dose adjustments. Finally, people with chronic pain can be reassured that waxing and waning is common, and that other stressful events in their lives can make pain seem worse. Often this helps patients to cope with residual anxiety about underlying problems that provide a secondary source of worry when pain seems less easy to control.