US Pharm. 2014;39(3):39-43.
ABSTRACT: Pain is often challenging to manage in
the geriatric population due to age-related changes that make drug
selection difficult. In addition, geriatric patients often have
comorbidities that can affect drug choice and lead to polypharmacy.
Polypharmacy and age-related changes increase the risk of drug
intolerance and drug interactions. The presence of dementia further
complicates pain management because of difficulties with pain assessment
and the increased risk of cognitive adverse events with commonly
prescribed medications. Uncontrolled pain in this population can also
contribute to behavioral issues that can be challenging for caregivers.
More than 36 million people worldwide are believed to suffer from dementia.1 The United States has the second largest population of people with dementia, about 4 million.1 A majority of cases of dementia occur after the age of 65 years.1 With rising growth rates in the elderly population, it is likely that the cases of dementia will increase accordingly.2
The prevalence of pain in U.S. adults 65 years and over is
variable. There are reports suggesting the rates of pain in geriatric
populations are around 21% (4 million people); most of this pain is
classified as persistent.2,3 Other studies have shown that over 90% of older adults experience pain, predominantly musculoskeletal.4 The prevalence of pain in dementia varies, largely based upon the assessment tools utilized in the studies.4,5
Assessment of Pain
As dementia progresses, the ability to communicate and
remember pain becomes increasingly difficult. These challenges cause
problems with the proper assessment of pain in this population. It is
widely acknowledged that pain is often undertreated in patients with
dementia, especially as dementia progresses. Often pain will be
displayed in the form of behavioral issues such as agitation,
combativeness, and wandering (TABLE 1).4,6
The current standard of pain assessment is patient self-report.5,7,8
Multiple pain scales exist that utilize the self-report such as the
visual analog scales, Faces Pain Scale, and Numeric Rating Scale.4,5,9 Due to their simplicity, these scales are deemed appropriate for use in patients with mild-to-moderate dementia.7,9
Assessment becomes increasingly troublesome in advanced dementia. In
some studies, self-report assessments have shown success. However,
observation scales are more appropriate in patients who are not able to
communicate, including the Pain Assessment Checklist for Seniors with
Limited Ability to Communicate (PACS-LAC), Observational Pain Behavior
Tool, Rating Pain in Dementia (RaPID), and Pain Assessment in Advanced
Dementia (PAINAD).4,9 These scales are routinely recommended to be performed in concert with an attempt at self-report.4,8,9
Medication Management Principles
Pharmacokinetic and pharmacodynamic changes due to aging
play a large role in the ability of this population to tolerate pain
medication. With increasing age comes decline in renal and hepatic
function. Reduced hepatic metabolism can lead to prolonged drug
half-life, thus increasing retention in the blood stream. For drugs that
are extensively metabolized via first-pass metabolism, there is a
possibility for increased bioavailability. Because of decreased muscle
mass and declining renal function, measures of serum creatinine are
often underestimated in the elderly, sometimes leading to overestimated
creatinine clearance values. Additionally, the half-life of renally
eliminated drugs is often increased due to reduced renal blood flow,
which can ultimately result in drug accumulation.7,10,11
Furthermore, volume of distribution is altered in patients
with increases in body fat and decreases in total body water and lean
muscle mass, which are commonly seen in older adults. Increases in
volume of distribution can delay a drug’s onset of action and
elimination rate, while reductions can cause increases in peak
concentrations. Drugs that are highly protein-bound can also be affected
by albumin levels, which can become low in elders with acute illnesses
or those who are frail. Gastrointestinal (GI) absorption or function
also changes during the normal aging process and can affect drug
absorption in some patients. Finally, anticholinergic effects (e.g.,
confusion, constipation) are more prominent in the elderly.7,10,11 TABLE 2 outlines the impact of these changes in relation to selected analgesics.11,12
The elderly typically have higher rates of polypharmacy
due to multiple comorbid conditions, which only increases the likelihood
that this patient population will present with adverse reactions to
Drug Selection Considerations
Considerations for drug selection should include type of pain, timing of pain (TABLE 3),7,9,13 and route of administration.7
Timing: Extended-release products can
be utilized in patients with higher short-acting medication demand to
potentially improve pain control and reduce pill burden. These patients
should have a short-acting product available for breakthrough pain. However,
because they may not be able to ask for them, patients with dementia
should not regularly be given pain medications on an as-needed basis. If
as-needed pain control is used, frequent pain assessment should be
performed. Finally, intensity of incident pain can be reduced with prior
scheduled pain medication (i.e., giving pain medication 30 minutes
preceding physical therapy).7
Route of Administration: It is
important to consider dosage forms when making recommendations for
patients with dementia. For those who have behavioral issues that make
medication management difficult (e.g., agitation, refusing to take
medications), consideration should be given to transdermal dosage forms
placed in locations from which they cannot easily be removed. For
patients with difficulty swallowing, mucosal, rectal, and transdermal
dosage forms are available.7
Acute pain should be managed with short-acting,
rapid-onset analgesics. For pain that is persistent, consideration
should be given to initial treatment with nonopioid analgesics. Opioid
analgesics should be used for pain nonresponsive to nonopioid agents.
Adjuvant analgesics are recommended for neuropathic pain. The Beers
criteria and the Consensus Guidelines for Oral Dosing of Primarily
Renally Cleared Medications in Older Adults are references that can be
used to assist in determining appropriate drug selection and dosing of
medications in older adults.14,15
Nonopioid Analgesics: Acetaminophen is used in this population as initial treatment because of its safety profile and efficacy.7
It is important to note that there have been many changes in the last
few years regarding dosing for acetaminophen. In 2011, McNeil Consumer
Healthcare (Tylenol’s manufacturer) reduced the maximum daily dose of
extra-strength acetaminophen to 3,000 mg when used for self-care in
response to the FDA recommendation regarding the sole utilization of the
325-mg dose in combination products.16,17 A maximum daily
dose of 4,000 mg is still allowable for regular-strength OTC
acetaminophen products or use of acetaminophen under the care of a
healthcare provider; however, due to previously mentioned
pharmacokinetic changes in the elderly, a maximum dose of 2,000 to 3,000
mg is recommended.12,18
Nonsteroidal anti-inflammatory drugs (NSAIDs) should be
used with extreme caution because of a higher association with GI
bleeding in the geriatric population.7,14 NSAIDs are most
commonly used when inflammation is present, for which steroids may be
alternatively used with caution. If NSAIDs are used, adjunctive therapy
for GI protection with a proton pump inhibitor (PPI) is warranted. The
use of topical NSAIDs at approved doses appears to be safe for periods
of <4 weeks because of seemingly low systemic absorption. It is
important to keep in mind that NSAIDs may also potentiate heart failure,
hypertension, and renal dysfunction.7
Opioid Analgesics: Treatment with opioids has shown efficacy in many types of pain, but these medications are not without adverse effects.7
These medications require monitoring and typically treatment for
associated complications. The majority of these agents are considered
appropriate in elderly patients, with the exception of meperidine, which
should be avoided due to high rates of neurotoxicity in patients with
renal dysfunction (TABLE 4).7,14
Adverse effects include constipation, sedation, cognitive
impairment, delirium, and respiratory depression. Constipation is one of
the more easily preventable adverse events associated with opioid use.
Upon initiation of an opioid pain regimen, patients can be scheduled on
an osmotic or stimulant laxative plus a stool softener such as docusate.
Patients should also be counseled on maintaining adequate hydration.
Because opioids decrease motility, secretions, and blood flow in the GI
tract, docusate alone is unlikely to be effective. In addition,
constipation does not lessen during treatment; thus, duration of
laxative treatment should parallel that of opioid use.7,13,19 If constipation is severe, consideration can be given to the use of transdermal fentanyl or buprenorphrine.11,19
While the amount of sedation may decrease with prolonged
opioid use, cognitive impairment is seen typically at drug initiation or
upward titration.19 It is reasonable to evaluate baseline
cognitive assessment prior to the initiation or upward titration of
opioids in patients with dementia. Care should be taken to limit or
avoid concurrent use of medications with anticholinergic or sedating
side effects to prevent worsening of sedation, cognitive function, or
While the risk of respiratory depression increases with
age, dose, and the presence of underlying pulmonary conditions,
tolerance does develop with continued use. Options for prevention
include low initial dosing with conservative titrations.11,19
Adjuvant Analgesics: Adjuvant
analgesics are strongly recommended for use in neuropathic pain, but can
be used for other types of pain as well. They are sometimes combined
with other analgesics for increased pain control. The term adjuvant drugs is used to group the antidepressant and anticonvulsant drug classes in pain management.7
While tricyclic antidepressants (TCAs) have shown efficacy in
neuropathic pain reduction, use of these agents in the elderly is not
recommended due to their strong anticholinergic properties and incidence
of sedation and orthostasis.7,14
Serotonin-norepinephrine reuptake inhibitors (SNRIs;
venlafaxine, duloxetine, milnacipran) are preferred above the TCAs for
neuropathic pain control in the elderly because of milder adverse-event
profiles. Their efficacy is thought to be related to the norepinephrine
reuptake inhibition. It is important to note that venlafaxine only
exhibits norepinephrine reuptake at higher doses. Doses of 150 mg per
day or greater have shown efficacy for neuropathic pain.20,21
The anticonvulsants gabapentin and pregabalin are also
used commonly for neuropathic pain control. Gabapentin can cause
sedation that lessens with drug use; thus, it should be started at a low
dose, such as 300 mg in the evening, and titrated slowly to effect.4,7 It can take several weeks to show improvement in pain control with gabapentin and around 1 week with pregabalin.7,22
Other Drugs: Other medications that
can be considered for treatment of pain in elderly demented patients
include corticosteroids, calcitonin, bisphosphonates, and topical
analgesics.7 Those with inflammatory disorders may experience
some additional relief with corticosteroids. For patients with
bone-related pain, there is some evidence that calcitonin may lessen
pain in compression and pelvic fractures. Pain associated with multiple
myeloma and breast or prostate cancer may be reduced with the use of
bisphosphonates. When considering topical analgesics, it is important to
recognize that the majority of supportive evidence for the lidocaine
patch is in neuropathic pain, although it appears to be less efficacious
than the adjuvant analgesics. In addition, while effective for
neuropathic and nonneuropathic pain, topical capsaicin is not well
tolerated because of the burning sensation associated with its use.7
There are other drugs that have been used to treat pain
that may not be appropriate for use in the elderly. Muscle relaxants can
increase the risk of anticholinergic-related adverse events as well as
sedation and should be avoided in the geriatric population.
Benzodiazepines should also be avoided due to their limited efficacy in
pain management and the increased risk of cognitive impairment,
delirium, and falls in older adults and those with dementia.7,14 Cannabinoids are not used often in geriatric patients because of the associated dysphoria.7
There is limited evidence available for nonpharmacologic
options for pain management in older adults. Therapies with supportive
evidence include exercise, music therapy, and acupuncture. Other
therapies that are commonly used include heat and ice therapy,
transcutaneous electric nerve stimulation, and cognitive-behavioral
The management of pain in patients with dementia can be
complicated due to comorbidities, polypharmacy, age-related
pharmacodynamic and pharmacokinetic changes that affect drug choice, and
difficulty in pain assessment, especially in advanced dementia. Even
so, there are many agents available for use in this population. The
regimen of each patient should be individually tailored. Medications
should be started at the lowest dosage and slowly titrated. Renal
function should be regularly assessed with medication change as
necessary. Examination of compliance, monitoring for adverse events, and
prevention of drug interactions should occur at every opportunity, as
should determination of the patient’s ability to report pain and request
as-needed medication.7,10 Regular assessment of a pain regimen can help to ensure better pain control in elderly patients with dementia.
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