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Chronic Pain, Aging, and Staying Healthy

Why are so many older people with chronic pain not getting the help they need?

As we grow older, many of us need to learn how to live with chronic pain.  

An estimated 60 to 75 percent of people over the age of 65 report having a problem with persistent pain and that rate is far higher for older people living in assisted care centres and nursing homes.    In the United States alone, there are more than 40 million people over the age of 65 and that number is expected to rise in the coming years as Baby Boomers grow older.   The majority of older Americans suffer from multiple conditions and the cost of treatment already accounts for more than two-thirds of the annual U.S. health budget.

The most common medical complains seen in older adults are osteoarthritis in the lower back and neck, musculoskeletal pain, chronic joint pain, and neuralgia linked to other conditions such as diabetes.   Not only does pain become more prevalent as people grow older, but women are generally more likely to report persistent pain than men.   While most older adults living with chronic pain tend to regard it as manageable for the most part, that can change as new medical conditions develop.

So how can we manage the pain problems that frequently arise as we grow older?   A new review article published in American Psychologist provides a comprehensive look at the numerous problems faced by older adults living persistent pain problems.    Written by Ivan R. Molton and Alexandra L. Terrill of the University of Washington Medical Center, the article identifies many of the barriers faced by older adults dealing with chronic pain and gives some directions for providing better care.

Dealing with chronic pain often means limiting the kind of activity that might make the pain worse.    Though this can seem like a sensible strategy for older adults,  becoming less active can also lead to a vicious cycle.  With reduced activity, people become less mentally and physically stimulated and more prone to becoming disabled over time.   Reduced activity also leads to less social interaction, weight gain due to reduced activity, and eventually even greater pain in the knees, back, and hips.  

Older people also have more difficulty sleeping, including getting up frequently at night, not being comfortable at night, and sleeping longer than usual.  With lack of proper sleep comes greater fatigue during the day, drowsiness, and a drop in mental and physical acuteness.  

Depressive symptoms are extremely common in older people with pain problems.   About 19 to 28 percent of all older adults with chronic pain report major depression issues and many reporting feeling suicidal as well.    The relationship between pain and depression tends to go in a cycle with increased pain leading to increased depression (and vice versa).

Along with pain and depression, older people can experience other problems which can aggravate the symptoms they are experiencing.   This can include substance abuse, being more socially isolated, financial problems (due to greater medical needs), and having a negative relationship with friends or family.    Adding to this is the frequent lack of mental health care available for older adults with pain and mental health issues.   According to research findings, almost half of all chronic pain patients with mental health problems fail to receive proper care. 

That is not to say that older adults with pain problems are necessarily going to develop mental health issues.  Most chronic pain patients handle their symptoms appropriately although that varies depending on the severity of the pain and the effectiveness of the pain relief they receive.  Not only are many older adults able to take their pain in stride (more or less), but they can avoid many of the mental health problems usually associated with chronic pain.

Still, older people suffering from chronic pain are at increased risk for depression and all the related problems that follow.   When assessing older people for pain problems, it is important for health care workers to ask questions about mental health issues and how well they are coping.    People with chronic pain also need to recognize the potential psychological problems that can occur and try their best to stay active and involved in their daily lives. 

While chronic pain can take a toll at any age, much of the research covered by Molton and Terrill has shown important differences between older and younger adults in how they cope with pain.    These differences can include:

  • pain perception  -   as we grow older,  our sensitivity to pain changes as well.   Many researchers have argued that older adults become less sensitive to pain due to changes in the peripheral and central nervous system though this has been disputed in recent years.   Direct comparison between older and younger research subjects show that pain awareness often varies depending on the type of pain involved.  Also, older people may experience chronic pain longer after an injury since their bodies heal more slowly.   
  • attitudes relating to pain  - since many older people often expect to develop pain problems as they grow older, they may downplay what they are experiencing.   They also tend to compare themselves to others of the same age who might be having similar health problems.    Since many older people may regard having pain as being perfectly normal, they might be more accepting than younger people experiencing chronic pain for the first time.   While the belief that chronic pain is a normal part of aging might seem reasonable for many people, it might also delay treatment that could help relieve that pain.  Older adults experiencing pain should ALWAYS seek medical advice to find the cause and investigate treatment options.   Also, people who are caring for older relatives complaining of pain should never dismiss these complaints either.
  • ways of coping -   as we grow older, we test out different strategies for coping with problems such as pain and anxiety.   Though research results tend to vary, older people use fewer pain coping strategies than younger people but they are also more effective due to their greater experience at "knowing what works."   Older adults are also better at pacing themselves and using their pain management strategies consistently instead of changing their pain management behaviour when the pain worsens.
  • social support and life context -  while older adults report fewer friends and social links than younger people,  they attach greater importance to the few close friends and relatives in their lives.   This appears to be due to an intentional "downsizing" in the size of their social support networks over time.   Since maintaining social relationships with a large circle of friends requires considerable time and energy, we tend to "weed out" the casual acquaintances and distant relatives who may not seem as important as when we were younger.    We can also lose old friends through death and our social networks become smaller over time.  For older people with chronic pain,  maintaining old friendships becomes even harder.   This is especially true when friends develop their own health problems and become less supportive as a result..  

So what are some of the medical problems faced by older people trying to cope with chronic pain that seems to get worse with time?   Some of the clinical issues discussed by Molton and Terrill include:

Chronic Pain and Medication

Many older adults dealing with chronic pain problems find themselves taking multiple pain remedies - prescription and non-prescription- on a daily basis.  A majority of older pain patients take between five and eight different medications while 12-39 percent take nine or more.   Medical visits involving older patients pleading with their doctors for more effective medications has skyrocketed in recent years and 40 percent of all over-the-counter pain remedies are taken by patients over the age of 65.   Along with problems associated with using so many pain medications, there is also the fact that the body's ability to process medication changes over time.   With aging comes reduced blood flow, more gastrointestinal problems, changes in muscle mass, and greater body fat.   This can lead to a need for higher dosages to achieve the same result as in younger patients.   It can also mean greater sensitivity to certain classes of medication because of changes to drug receptor sites in the body.   Older patients are more prone to developing side effects from medication, including constipation, sleep problems, mental confusion, and balance problems.   To avoid problems, medication needs to be carefully monitored in older patients, even more than  in younger patients, to ensure maximum benefit.

Cooperating with Treatment

With older patients, staying healthy often involves complying with a wide range of different treatments, including different types of medication.   In many cases however, older patients can be reluctant to take pain medication as prescribed and often take a lower-than-prescribed dose instead.   Even patients dealing with severe pain may only take medication "as needed" rather than as their doctors prescribe.   Older patients are often reluctant to take pain medication as prescribed due to worrying about possible side effects and even becoming addicted to pain medication.  For older pain patients, patient education training can help them overcome misconceptions about addiction that might encourage them to sabotage their own treatment.  

Dementia Fears

Older patients dealing with chronic pain may also fine themselves at increased risk for dementia.  With their pain comes additional symptoms that can contribute to problems in memory and concentration.   Also, people with dementia can also develop pain problems due to urinary tract infections, bedsores, and fractures from falling.   This can make their dementia harder to manage as pain leads to agitation, sleep problems, and trouble with walking.   There is also a misconception that people with dementia feel less pain which can lead to pain problems going undiagnosed or untreated far longer than necessary.   Dementia patients who have trouble communicating may not be able to inform others about their pain symptoms and family members caring from them often need to rely on changes in behaviour to determine whether they are in pain. 

As Ivan Molton and Alexandra Terrill point out, older adults are far more likely to underreport pain than younger people.    Whether through problems with hearing, cognitive issues, or attitudes about pain and aging, many older people often choose to be "stoic" about pain rather than asking for treatment.    Fear seems to be a major factor in many older people choosing not to report pain problems.   Whether through fear of being labelled a hypochondriac or being seen as a burden,  older people with pain problems may simply choose to live with their pain rather than reporting it.  Unfortunately, this can also mean allowing medical problems to go untreated much longer than necessary, especially if the pain grows worse with time.   

Along with personal barriers to receiving treatent, there are also the multiple barriers in the health care system than often prevent older adults from getting proper medical cares.   Health insurance claims,  financial limitations, lack of transportation, and a shortage of  health professionals with training in dealing with geriatric issues can mean critical delays in getting needed treatment.   Many doctors can have their own misconceptions about pain and aging, including the belief that pain is a normal part of aging, and may be reluctant to prescribe pain medication that can help symptoms. 

In concluding their article, Molton and Terrill argue that clinical psychologists need to become better educated in pain management, especially when dealing with older patients.   At present, only 22 percent of doctoral clinical programs offer a formal course in pain management while many practicing psychologists report no formal pain management education of any kind.     Since emotional problems such as depression are often linked to chronic pain, psychologists working as part of a treatment team with other health professionals can help older patients with pain problems get treatment more quickly and avoid needless suffering. 

As more Baby Boomers enter their retirement years, the need for expanded geriatric programs addressing health issues such as chronic pain is becoming much more critical.    Though new types of treatment would certainly be welcome, it is far more important that health providers make existing treatments available to all people who need them.  Making certain that older patients with chronic pain have access to health care as they need it is a challenge that patients, families, and health care providers need to meet together. 

Romeo Vitelli, Ph.D. is a psychologist in private practice in Toronto, Canada.

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