Key Point
Fifty-six percent of nursing home residents with cognitive impairment received pain medications vs 80% of those with intact cognition.
Sensory impairment. Patients with visual deficits may have difficulty reading prescription bottle labels and information sheets. Those with auditory deficits may have trouble hearing, communicating, and understanding treatment instructions during a busy clinical encounter.
Sociodemographic factors. Many older adults live alone and have limited social support to encourage medication adherence.24 Some have significant caregiving responsibilities of their own (such as a spouse in poor health), which can lead to stress and inconsistent use of prescribed medications.25 Some older adults can’t afford the costs of certain pain medications and may take less than the prescribed amount.
Many older adults lack the necessary skills to read and process basic health care information, including understanding pill bottle instructions, information that appears in patient handouts, and clinicians’ instructions about possible adverse effects.26,27 Low health literacy can lead to problems with medication adherence (taking too much or too little of an analgesic medication) and associated complications.
Health beliefs. Many older adults believe chronic pain is a natural part of aging; in one study, this was true of 61% of approximately 700 primary care patients with osteoarthritis pain.28 Some older adults believe pain only gets worse over time,28 and others believe treatment for pain is not likely to provide any meaningful benefit.29,30 Beliefs such as these can lead to stoicism or acceptance of the status quo.31
Older adults also may endorse beliefs about pain medications that are likely to decrease their willingness to engage in, or adhere to, recommended pharmacologic interventions. Some use pain medicines sparingly because they fear addiction or dependence.32,33 Caregivers—often a spouse or adult child—also may express fears about the possibility of addiction.32 Finally, some older adults believe that using prescription analgesic medications invariably results in adverse effects;32 those who endorse this belief report minimizing medication use except when the pain is “very bad.”34
Recommendations. Elicit concerns patients may have about using analgesic medications and discuss them openly. Although not all barriers (such as economic issues) are modifiable, most (such as beliefs that pain medications are addictive) can be successfully addressed through patient education.
If other social support, such as a family member or caregiver in the home, could positively affect analgesic engagement/adherence, include these facilitators when discussing treatment decisions and in monitoring for medication effectiveness and adverse effects.
Step 5. Start low and go slow when initiating analgesia
Advancing age is associated with increased sensitivity to the anticholinergic effects of many commonly prescribed and OTC medications, including NSAIDs and opioids.35 Increasing the anticholinergic load can lead to cognitive impairments, including confusion, which can be particularly troublesome for older adults.1
Changes in pharmacokinetics (what the body does to the drug in terms of altering absorption, distribution, metabolism and excretion) and pharmacodynamics (what the drug does to the body in the form of adverse effects) occur as a function of advancing age. 1 Body fat increases by 20% to 40% on average, which increases the volume of distribution for fat-soluble medications.16 Hepatic and renal clearance decrease, leading to an increased half-life and decreased excretion of medications cleared by the liver or kidneys. Age-associated changes in gastrointestinal (GI) absorption and function include slower GI transit times and the possibility of increased opioid-related constipation from dysmotility problems.1
As a result of these physiologic changes, advancing age is associated with a greater incidence of drug-related adverse effects. Even so, individuals within the older population are highly heterogeneous, and no geriatric-specific dosing guidelines exist for prescribing pain medications to older adults.
Recommendations. We recommend the adage “start low and go slow” when initiating an analgesic trial for an older patient with chronic pain. This does not mean you should “start low and stay low,” which can contribute to undertreatment.36 If treatment goals are not being met and the patient is tolerating the therapy, advancing the dose is reasonable before moving on to another intervention.
Key Point
We recommend that you “start low and go slow” but this does not mean that you should “start low and stay low.”
Step 6. Assess for effects and outcomes outside the office
Adverse effects are a primary reason older adults discontinue an analgesic trial.37 Make certain the patient (or caregiver, as appropriate) understands what adverse effects might occur, and create a plan to address them if they do.
Recommendations. Because many older people are reluctant to communicate with their physicians outside of an office visit, establish how often and when communication should occur. Telephone calls and/or e-mail are practical tools for patients to communicate questions or concerns to you, and you can enhance treatment outcomes with timely replies. In the near future, mobile health technologies may play a key role in monitoring for adverse effects and communicating positive treatment outcomes.