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Spotlight on Aging: Pain

Spotlight on Aging: Pain

Pain is common among older people. However, as people age, they complain less of pain. The reason may be a decrease in the body’s sensitivity to pain or a more stoical attitude toward pain. Some older people mistakenly think that pain is an unavoidable part of aging and thus minimize it or do not report it.

The most common cause is a musculoskeletal disorder. However, many older people have chronic pain, which may have many causes.

Effects of pain may be more serious for older people:

  • Chronic pain can make them less able to function and more dependent on other people.

  • They may lose sleep and become exhausted.

  • They may lose their appetite, resulting in undernutrition.

  • Pain may prevent people from interacting with others and from going out. As a result, they can become isolated and depressed.

  • Pain can make people less active. Lack of activity can lead to loss of muscle strength and flexibility, making activity even more difficult and increasing the risk of falls.

Older People and Pain Relievers

Older people are more likely than younger people to have side effects from pain relievers (analgesics), and some side effects are more likely to be severe. Analgesics may stay in the body longer, and older people may be more sensitive to them. Many older people take several drugs, increasing the chances that a drug will interact with the analgesic. Such interactions may reduce the effectiveness of one of the drugs or increase the risk of side effects.

Older people are more likely to have disorders that increase the risk of side effects from analgesics.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can have side effects. Risk of several of side effects is higher in older people, particularly if they have several other disorders or are taking NSAIDs in high doses. For example, older people are more likely to have a heart or blood vessel (cardiovascular) disorder or risk factors for cardiovascular disorders. For people with these disorders or risk factors for them, taking NSAIDs increases their risk of having a heart attack or stroke and of developing blood clots in the legs or heart failure.

NSAIDs can damage the kidneys. This risk is higher for older people because the kidneys tend to function less well as people age. This risk of kidney damage is also higher in people with a kidney disorder, heart failure, or a liver disorder, which are more common among older people.

Older people are more likely to develop ulcers or bleeding in the digestive tract when they take NSAIDs. Doctors may prescribe a drug that helps protect the digestive tract from such damage. These drugs include proton pump inhibitors (such as omeprazole) and misoprostol.

When older people take NSAIDs, they should tell their doctor, who then evaluates them periodically for side effects. Doctors also recommend the following for older people if possible:

  • Taking low doses of NSAIDs

  • Taking them for only a short time

  • Taking breaks from using NSAIDs

Opioids are more likely to cause problems in older people, who appear to be more sensitive to these drugs than younger people. When some older people take an opioid for a short time, it reduces pain and enables them to function better physically, but it may impair mental functioning, sometimes causing confusion.

Opioids also increase the risk of falls and cause constipation and urinary retention, which tend to cause more problems in older people.

Problems with overuse of opioids have increased over the last several years.

Older people are more likely to have conditions or take drugs that can make them more likely to have side effects from opioids, such as the following:

  • Impaired mental function: Opioids can make already impaired mental function worse.

  • Respiratory disorders (such as chronic obstructive pulmonary disease or obstructive sleep apnea): Opioids can cause people to breathe more slowly (called respiratory depression) or even stop breathing (called respiratory arrest). Respiratory arrest is often the cause of death in overdoses. Having a respiratory disorder increases the risk of respiratory depression, respiratory arrest, and death due to opioids.

  • Liver or kidney disorders: In people with a liver or kidney disorder, the body cannot process and eliminate opioids normally. As a result, the drugs may accumulate, increasing the risk of an overdose.

  • Use of other sedatives: Sedatives, including benzodiazepines (such as diazepam, lorazepam, and clonazepam), can interact with opioids and make people extremely drowsy and dizzy. Both opioids and sedatives slow breathing, and taking both slows breathing even more.

To reduce the risk of side effects, particularly when prescribing opioids, doctors give older people a low dose at first. The dose is increased slowly as needed, and its effects are monitored. Doctors also choose analgesics less likely to have side effects in older people. For example, acetaminophen is usually preferred to NSAIDs for treating chronic mild to moderate pain without inflammation. Certain NSAIDs (indomethacin and ketorolac) and certain opioids (such as pentazocine) are usually not given to older people because of the risk of side effects. If opioids are necessary, buprenorphine may be a good choice, especially for older people with a kidney disorder, because it may have a lower risk of side effects than other opioids.

Many older people are understandably concerned about the risks of opioid addiction. However, the risk is low when a person takes opioids as prescribed, low doses are prescribed, and opioid use is monitored by a single health care practitioner or team of practitioners who are providing coordinated care to the person. The risk is higher if people have been addicted or have a close family member who has been addicted to alcohol, opioids, or other drugs.

Nondrug treatments and support from caregivers and family members can sometimes help older people manage pain and reduce the need for analgesics.