Pain management in older adults Patricia Schofield Abstract We are seeing a significant increase in the older population far out- weighing that in younger cohorts, and this is set to dramatically increase by 2050. With increasing age comes an increased risk of co-morbidities and consequently a likelihood of pain. Pain is a com- mon problem for older adults; many reports suggest that the incidence is around 50% in older adults living in the community, increasing to 80% among the nursing home population. Dealing with pain in this population is complex and becomes even more challenging when cognitive impairment exists. This article highlights the challenges, pro- poses strategies for the assessment and management of pain in the older population and makes recommendations for future research in this area. Keywords Ageing; assessment; management; pain Introduction Our population is ageing, with a significant increase in the number of older adults anticipated over the next 25 years, and a decrease in younger counterparts. So we are expecting to see the ratio of older adults increase to that of younger adults. With this will come a higher number of older adults with cognitive im- pairments. There are already around 850,000 older adults with dementia in the UK. Therefore an ageing population coupled with an increase in co-morbidities and potential communication dif- ficulties is likely to present future challenges to pain assessment and management. Historically, evidence has suggested that pain is a common problem for older people, with chronic persistent pain affecting at least 50% of community-dwelling older adults, the figure increasing to 80% among those living in care homes. More recent systematic reviews of the literature confirm that this is still the case. 1 As the percentage of our ageing population increases over time (Figure 1), greater demands will be placed on healthcare professionals and informal carers to cope with the problems associated with old age, especially pain assessment and management. Pain management in older adults is generally poor. The rate of admission to hospital for patients >65 years of age is three times higher than for younger people, and there is evidence that pro- fessionals tend to underestimate pain needs, underprescribe and undermedicate. This may in part relate to fears and mis- conceptions among prescribers regarding pre-existing co-mor- bidities and the effects of prescribed medicines. Such fears and anxieties are not totally unfounded as older adults tend to have co-morbidities, with concurrent medications prescribed. They are also more likely to have diminished functional status and physiological reserve, as well as age-related pharmacodynamic and pharmacokinetic changes. Cognitive impairment can prevent or complicate adequate pain assessment. In all care settings, healthcare professionals should be aware of pain assessment tools that can be used with older adults e both those who can communicate their pain and those unable to do so as a result of cognitive impairment. It is frequently assumed that chronic pain is simply a part of getting older and something the individual must learn to live Key points C We are facing a significant increase in the ageing population, which will be accompanied by a significant number of older adults with communication difficulties such as dementia C Pain is a common problem in the ageing population and in- creases significantly in those living in nursing homes C Pain management is generally poor, with poor pain assess- ment, underprescribing and underadministration C There is recommended guidance on pain assessment for this group, as well as behavioural scales that can be used when there are communication difficulties C Numerical rating scales and verbal descriptors are appropriate for older adults, but the approach may need to be varied C The Abbey, PAINAD and DOLOPLUS scales are recommended where the adult has cognitive impairment C Most research around management has been conducted with younger adults and simply translated to older adults C Paracetamol is the drug of choice for pain management. Opi- oids can be used, but the approach should be to ‘start low, go slow’ C Some invasive treatments for chronic pain are effective, but more research is needed. Patricia Schofield RGN PhD PGDipEd DipN is Professor of Nursing, Deputy Dean Research and Income Generation, Anglia Ruskin University, UK. She has completed several postdoctoral projects around pain management in older people, including talking to them about their pain experiences, with funding from the MRC, EU and ESRC. She recently published the national guidelines for the management of pain in older adults and updated the national pain assessment guidelines for older adults, both after a working party of the British Geriatrics Society and British Pain Society. She is involved in a number of other studies including the pain assessment application evaluation (iPhone APP) with paramedics, a positive ageing peer education project and an end-of-life and dementia project. She has written over 150 peer-reviewed publications and a number of books in this field and spoken at many national and international conferences. Competing interests: none declared. MEDICINE IN OLDER ADULTS MEDICINE --:- 1 Ó 2016 Published by Elsevier Ltd. Please cite this article in press as: Schofield P, Pain management in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.005