Chronic Pain is a major public health challenge globally. One in every five adults worldwide suffers from pain, and one in every ten adults is diagnosed with chronic pain each year. Though there is little data available in the Indian context, but study shows a CP prevalence of 19.3% in India. Rural population, particularly females suffer more unrelieved and untreated pain. Studies have shown that pain severely affects almost all segments of life i.e. sleep, ability to exercise, perform household chores, walk, attend social affairs, and maintain independent lifestyles, and may lead to depression or anxiety and economic burden on households due to increased treatment costs. In short it leads to loss in quality of life.
WHO has recognised pain as a distinct disease in its 11th revision of the International Classification of Diseases (ICD-11). The International Association for the Study of Pain (IASP) defined pain as “an unpleasant sensory and emotional experience associated with or resembling that associated with, actual or potential tissue damage. Pain can broadly be categorised into two types i.e. acute and chronic often distinguished based on duration. If pain persists for more than three months, it is termed as chronic pain and if it persists for less than 3 months it is termed as acute pain.
Types of Chronic Pain in Elderly
Studies has shown that Elderly people tolerate acute pain better when compared to persistent pain. This might be correlated with differences in duration and origin/cause of chronic and acute pain. Sensory mechanisms (defective neuroplasticity or impaired nociceptive pathways), behavioural components (such as superior pain acceptance and self-efficacy, and less catastrophizing levels), as well hormonal (estrogen), and social factors (social support) can influence pain perception in the elderly. However chronic pain has been broadly classified as,
Age-related changes: As individuals age, changes in the musculoskeletal system, such as decreased bone density, muscle mass, and joint flexibility, can contribute to chronic pain. Conditions like osteoarthritis, degenerative disc disease, and spinal stenosis are more prevalent in older adults and can lead to persistent pain. Age-related changes in the nervous system, including decreased nerve function and slower nerve conduction, may also contribute to the development of chronic pain conditions like neuropathy and neuralgia
Underlying Health Conditions: Along with age, chances of developing chronic conditions also increases. Chronic health conditions, such as diabetes, cardiovascular disease, and cancer, can be associated with chronic pain. These conditions may cause pain directly or indirectly through complications and comorbidities. Chronic conditions like fibromyalgia, rheumatoid arthritis, and inflammatory bowel disease are more common in older adults and can lead to widespread or localised pain that persists over time
Past Injuries and Trauma: Previous injuries, surgeries, or traumatic events experienced earlier in life can contribute to chronic pain in older adults. Scar tissue formation, nerve damage, and changes in biomechanics following injuries may lead to persistent pain in affected areas. Traumatic experiences such as accidents, falls, or sports injuries can also result in long-term pain conditions, especially if they were not adequately treated or managed at the time of occurrence
Lifestyle Factors: Sedentary lifestyle habits, poor posture, and inadequate physical activity can exacerbate musculoskeletal pain and contribute to the development of chronic pain conditions in older adults. Lack of movement and muscle weakness can lead to stiffness, joint instability, and decreased flexibility. Unhealthy lifestyle behaviours such as smoking, excessive alcohol consumption, and poor nutrition can also negatively impact pain perception and exacerbate chronic pain in the elderly.
Psychological factors: Psychological and emotional factors, including stress, anxiety, depression, and social isolation, can significantly influence the experience of chronic pain in older adults. Mental health conditions may exacerbate pain symptoms and reduce pain tolerance, leading to greater disability and functional impairment.
Consequences of Chronic Pain in elderly
Diminished Quality of Life: Chronic pain significantly impacts daily activities, reducing the overall quality of life for older adults.
Impaired Functional Independence: Pain-related limitations can hinder the ability to perform self-care tasks and maintain independence.
Increased Psychological Distress: Persistent pain can lead to anxiety, depression, and a sense of hopelessness.
Risk of Social Isolation: Difficulty participating in social activities due to pain can lead to isolation and loneliness.
Exacerbation of Underlying Conditions: Inadequately managed pain can exacerbate other health conditions, worsening health.
Elevated Healthcare Utilization: Ineffective pain management can lead to frequent medical visits, emergency room trips, and hospitalizations.
Potential Cognitive Decline: Chronic pain has been associated with cognitive decline in older adults.
Negative Impact on Caregivers: Unmanaged pain can increase the burden on caregivers and affect their well-being.
Overall Well-being Compromised: The combined effects of pain-related challenges can significantly compromise the overall well-being of older individuals.
Comprehensive approach to manage chronic pain in elderly
A comprehensive assessment of the older person in pain involves identifying its cause, establishing its severity, determining its impact on the person and reviewing the person’s response to treatment. Six steps approach has been considered helpful for managing CP in elderly
Approach to chronic pain is broadly classified as Pharmacologic and Non pharmacologic.
| Medications commonly used in managing chronic pain | ||
| Medication Class | Examples | Special considerations |
| Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): | ibuprofen, naproxen, and diclofenac | Older adults are at higher risk of gastrointestinal bleeding, cardiovascular events, and kidney dysfunction, so careful monitoring and use of the lowest effective dose are essential. |
| Acetaminophen (Paracetamol): | Acetaminophen | It is considered safer than NSAIDs in terms of gastrointestinal and cardiovascular risks but may still pose a risk of liver toxicity, especially in those with pre-existing liver disease or alcohol use. |
| Opioid Analgesics | oxycodone, hydrocodone, and morphine | Prescribed for severe chronic pain when other treatments have been ineffective. Older adults may be more sensitive to the side effects of opioids, including sedation, respiratory depression, constipation, and falls, so careful titration and monitoring are necessary to minimize risks. |
| Tricyclic Antidepressants (TCAs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) | TCAs, such as amitriptyline, and SNRIs, such as duloxetine | Used for neuropathic pain management in conditions like diabetic neuropathy and fibromyalgia. Older adults may be more susceptible to adverse effects such as orthostatic hypotension, cognitive impairment, and anticholinergic effects with TCAs, so cautious prescribing and monitoring are advised |
| Anticonvulsants: | Gabapentin and pregabalin are used for neuropathic pain | Older adults may experience dizziness, drowsiness, and gait disturbances with anticonvulsants, so dose adjustments and gradual titration are recommended |
| Topical Analgesics | Topical agents such as capsaicin and lidocaine patches | Can provide localized pain relief for conditions like osteoarthritis and neuropathy. These agents are generally well-tolerated in older adults, with minimal systemic side effects compared to oral medications |
Non-pharmacological approaches to managing chronic pain in older adults
Physical therapy: Physical therapy involves exercises, stretches, and manual techniques aimed at improving strength, flexibility, and range of motion, which can help alleviate chronic pain in the elderly. Therapeutic modalities such as heat therapy, cold therapy, ultrasound, and electrical stimulation may also be used in conjunction with physical therapy to reduce pain and improve function
Occupational Therapy: Occupational therapy focuses on improving the ability to perform activities of daily living (ADLs) and adapting the environment to promote independence and reduce pain. Techniques such as joint protection, energy conservation, and ergonomic modifications can help older adults with chronic pain manage their symptoms more effectively
Cognitive-Behavioral Therapy (CBT): CBT is a psychological therapy that helps individuals identify and change negative thought patterns and behaviors associated with chronic pain. Techniques such as relaxation training, guided imagery, mindfulness meditation, and stress management can help older adults develop coping skills and reduce the perception of pain
Pain Education and Self-Management Programs: Pain education programs provide information about the nature of chronic pain, strategies for pain management, and resources for self-care. Self-management programs empower older adults to take an active role in managing their pain through techniques such as pacing activities, setting goals, and using pain diary tools
Acupuncture and Acupressure: Acupuncture involves the insertion of thin needles into specific points on the body to stimulate nerve pathways and promote pain relief. Acupressure applies pressure to the same acupuncture points using fingers, hands, or devices to achieve similar therapeutic effects
Massage therapy: Massage therapy involves manipulating soft tissues and muscles to reduce muscle tension, improve circulation, and promote relaxation, which can alleviate chronic pain in the elderly. Techniques such as Swedish massage, deep tissue massage, and myofascial release are commonly used for pain management
Mindfulness-Based Stress Reduction (MBSR): MBSR is a structured program that combines mindfulness meditation, yoga, and body awareness techniques to reduce stress and enhance pain management skills. Older adults can benefit from MBSR by learning to cultivate present-moment awareness and develop a non-judgmental attitude towards their pain
Water therapy: Dehydration can increase sensitivity to pain. It can also have other effects on health outcomes, especially in older populations, such as poor wound healing and constipation. Water is essential for circulation of nutrients and waste elimination both of which can influence healing, and pain
Digital Therapy: The use of software, mobile applications, sensors, and other digital approaches as therapeutic interventions to address various medical problems is known as digital therapy. Digital therapies refer to all of these devices and methods together. In essence, digital treatment is not dissimilar to traditional face-to-face therapeutic procedures. The cognitive behavioral therapy technique is used in the majority of digital therapy practices. It focuses on the notion of providing frequent counselling to patients to improve their behavioural and lifestyle habits
Lifestyle Modification: Lifestyle factors like physical inactivity, sedentary behavior, stress, poor sleep, unhealthy diet, smoking, alcoholism and drugs are associated with chronic pain severity and sustainment. Quit smoking and alcoholism, they not only degrade our general health but also affect the musculoskeletal system. They delay healing and aggravate chronic pain.
Dietary and Nutritional Interventions: Certain dietary and nutritional interventions, such as anti-inflammatory diets rich in fruits, vegetables, whole grains, and omega-3 fatty acids, may help reduce inflammation and alleviate chronic pain. Supplements such as turmeric, ginger, omega-3 fatty acids, and vitamin D have also been studied for their potential analgesic effects
Chronic pain in the elderly is a multifaceted issue influenced by various factors, including age-related changes, underlying health conditions, past injuries, lifestyle factors, and psychosocial factors. Understanding these common contributors to chronic pain is essential for healthcare professionals to develop comprehensive treatment plans that address the complex needs of older adults experiencing persistent pain. By addressing the underlying causes and implementing appropriate interventions, it is possible to improve pain management outcomes and enhance the overall quality of life for elderly individuals living with chronic pain.
In the next article, we would list 10 fruits that help in reducing chronic pain.
Reference articles
Indian Journal of Palliative Care, October 2018: The Prevalence of Chronic Pain among Adults in India – Ashok Kumar Saxena, Parmanand N Jain1, Sushma Bhatnagar,
Chronic Pain in the Elderly: Mechanisms and Perspectives, Ana P A Dagnino and Maria M Campos. https://www.frontiersin.org/articles/10.3389/fnhum.2022.736688/full
The silent epidemic of chronic pain in older adults, Anthony F. Domenichiello, Christopher E. Ramsden, https://www.sciencedirect.com/science/article/abs/pii/S0278584619300831
Special consideration for pain management in the older person, Terence Ong and Chiann Ni Thiam: https://www.rcpjournals.org/content/clinmedicine/22/4/295
Dietary Patterns and Interventions to Alleviate Chronic Pain, Simona Dragan, Maria-Corina Șerban, Georgiana Damian, Florina Buleu,1 Mihaela Valcovici, and Ruxandra Christodorescu. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7551034/
Nutrition and Chronic Pain (International association for the study of pain, https://www.iasp-pain.org/resources/fact-sheets/nutrition-and-chronic-pain/