Chapter 14: Pain Management in Older Adults

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Welcome back to the Deep Dive.

Today we are opening a file that is absolutely fundamental to yet, as we're going to find out, is often uncomfortable, misunderstood, and frankly, frequently mishandled.

We're digging into Chapter 14 of Gerontologic Nursing,

and the topic is pain.

Specifically, pain assessment and management in older adults.

And you're right, uncomfortable is exactly the right word.

I mean, it sits right at the intersection of biology, psychology, and our own mortality.

Right.

So if you are a nursing student, a caregiver, or just someone with aging parents, this is kind of the monster under the bed you have to learn to tame.

It really is.

I think most people have probably heard the phrase, pain is the fifth vital sign, right?

We check pulse, temperature, blood pressure, respiration,

and then pain.

It's supposed to be right up there on the dashboard of human health.

Well, that's the theory anyway.

The whole for the fifth vital sign was launched to make pain a priority, to treat it almost like a physiological emergency.

An emergency.

Yeah.

The idea is that when the body systems are working in harmony, you shouldn't feel pain.

So when pain is present, it's an alarm bell.

It's telling us something is wrong.

But here's the kicker.

And this was the first thing that really, really jumped out at me from the text.

There is this massive pervasive myth floating around.

Oh, it's huge.

And not just among the public, but even sometimes among healthcare professionals, that pain is just a normal part of getting older.

You know, that whole, what do you expect at your age?

Right.

That is the big myth.

And it is so dangerous.

We need to be crystal clear about this right from the start.

Pain is a symptom of disease or injury.

Okay.

It is never ever a normal result of aging.

Aging brings changes, you know, gray hair, slower metabolism, thinner skin.

But pain is not on that list.

If an 85 year old is in pain, it's not because they are 80.

It's because something is wrong.

It's because there is a pathology like osteoarthritis or neuropathy that needs to be found and addressed.

I feel like that attitude, oh, it's just arthritis.

You're old.

It's just so dismissive.

It essentially tells the patient, hey, get used to it.

It does.

And the consequences of that dismissal are, well, they're staggering.

The text notes that something like 25 to 50 % of community dwelling older adults experience significant pain, which is already a lot.

It is.

But when you look at nursing homes, that number jumps to 70 or 80%.

Wow.

Up to 80%.

That is a massive number of people who are suffering.

And a huge portion of that is undertreated.

And we are just talking about discomfort here.

We are talking about a cascade of negative outcomes.

The text outlines this really vicious cycle.

Pain leads to immobility.

I mean, if you hurt, you stop moving.

Of course.

And if you stop moving, you lose muscle mass, you get constipated, your risk of pneumonia just skyrockets.

Then comes the depression, the social isolation,

and huge financial costs.

It's a total collapse of quality of life.

So that is our mission for this deep dive.

We are going to translate this chapter into really a practical guide for the nursing student or anyone who's listening.

We're going to break down the physiology,

the assessment tools, which are way trickier than I thought.

They really are.

The specific challenge of dementia and all the medication protocols.

Yeah.

We have a lot to cover, especially around pharmacokinetics, how drugs actually move through an older body, and how you have to become a detective when the patient literally can't tell you what hurts.

Okay.

Let's unpack this.

Segment one, defining the enemy.

What actually is pain?

Because the text gives a few definitions, but there's one from Margot McCaffrey that seems to be the gold standard.

It is.

McCaffrey's definition is deceptively simple.

She says pain is whatever the experiencing person says it is, existing whenever he or she says it does.

Whatever the person says it is.

Yeah.

That puts a lot of power in the patient's hands.

As a scientist, doesn't that bother you a little?

There's no blood test for pain.

It drives some clinicians crazy because we love objective data.

We want to see the broken bone on the x -ray or the infection in a blood count,

but pain isn't like that.

So there are no biomarkers at all.

None.

There are no biological markers for pain.

We can't measure it objectively.

Two people can have the exact same surgery, and one rates their pain a three and the other an eight.

And here is the key.

They are both right.

Because their brains are processing it differently.

Exactly.

The brain is the final judge.

It filters that incoming signal through memory, through culture, fear, anxiety, all of it.

So at the end of the day, the patient is the ultimate and only on their own suffering.

Right.

Okay.

Now, once we accept that pain is what the patient says it is, we have to classify it to treat it.

The text distinguishes between acute pain and persistent pain.

And I noticed they specifically use the term persistent pain rather than chronic pain.

Why the shift in language?

It's all about the psychological baggage.

The word chronic carries a stigma.

How so?

It just sounds hopeless, doesn't it?

Like a life sentence of complaining.

You hear chronic back pain and you think chronic complainer.

Persistent, on the other hand, is just a clinical descriptor.

It's more neutral.

It is.

It just means the pain is continuing after healing should have occurred, or it's associated with an incurable condition.

It frames it as a condition to be managed, not a character flaw.

I like that.

Words really do matter.

Yeah.

So within persistent pain, the American Geriatric Society breaks it down into four categories.

Let's run through those because they really dictate the treatment.

You don't just throw Tylenol at everything.

Not at all.

Category one is nociceptive.

Nociceptive pain is your standard hardware damage.

It involves the stimulation of pain receptors.

So tissue inflammation, an injury, mechanical deformation.

This is your arthritis, your back pain, a cut, a broken bone.

Okay.

That seems straightforward enough.

And it usually responds well to common analgesics because you are treating the inflammation or the injury directly.

Okay.

Makes sense.

Number two, neuropathic.

This is the tricky one.

This is pathophysiology in the nervous system itself, either the peripheral nervous system or the central nervous system.

So this is more of a software or a wiring issue.

That's a great way to put it.

The tissue might be healed, but the nerves themselves are misfiring.

Examples would be diabetic neuropathy, or that awful post -opetic neuralgia you can get from shingles.

And traditional painkillers don't work as well here.

Exactly.

You're dealing with a wiring issue, not a tissue issue.

So you use unconventional drugs like antidepressants or anticonvulsants drugs that calm down those electrical storms in the nervous system.

Which we will definitely get into later in the pharmacology section.

Then we have mixed or unspecified pain, which I assume is well, exactly what it sounds like.

Yep.

Mixed mechanisms.

It requires some trial and error.

And finally, the fourth category is psychological pain.

Things like somatization disorders.

This is rare, but it does exist.

But the text gives a warning here.

A very strong warning.

Do not use psychological pain as a dump bin for patients you just don't understand.

In other words, don't assume it's in their head just because you can't find the source.

Precisely.

We must believe the patient first.

Always.

Okay.

So that's the definition.

Now let's move to segment two.

The physiology of pain and age -related changes.

How does this signal actually travel?

The text breaks it down into afferent, CNS, and Everett pathways.

It almost sounds like a commute.

It is a commute, a very fast one.

Think of the afferent pathways as the road in.

You have these things called nociceptors, nerve endings in the skin, that pick up mechanical, thermal, or chemical stimuli.

Like a hot stove or a paper cut.

Right.

They transduce that into an electrical signal and send it zipping up the spinal cord.

And then it hits the brain, the central nervous system.

Right.

The signal arrives, and this is where perception happens.

It hits the limbic system, the thalamus, the cortex, and this is crucial.

The brain interprets that signal based on physical factors, yes, but also on psychological ones.

Memory, culture, fear, all of that shakes how much pain you actually feel.

So if I'm terrified of hospitals, the pain might actually feel worse than if I were calm.

Oh, absolutely.

The brain is not just a passive receiver.

It's an amplifier or a dampener.

It turns the volume up or down.

And then you have the efferent pathways, the road back down where the body reacts.

And the text mentions substance P.

Yes.

Substance P is a neurotransmitter that facilitates this transmission.

It's like the grease on the wheels of the pain signal, helping it move along smoothly.

Now here is where it gets really interesting and honestly a little scary for our older adult population.

The text talks about atypical presentation.

This is so, so vital for nurses to understand.

As we age, our nervous system changes, we lose neurons, neurotransmitters change.

The way we perceive and report pain, it changes too.

And that leads to some dangerous situations.

It really does.

You get older adults with serious life -threatened conditions who just don't show the classic symptoms.

The examples they gave are parifying, a silent myocardial infarction, a heart attack with no chest pain.

Is that real?

It is very real or painless appendicitis.

A young person with appendicitis is doubled over in agony, screaming.

An older adult, they might just seem a little confused, maybe have a mild tummy ache or simply stop eating.

That is wild.

So if a nurse is just waiting for the textbook screaming and pain symptoms, they could miss a life -threatening event.

Exactly.

You cannot rely on the symptoms you learn for populations.

Confusion, or what we call acute delirium, is often the only sign of a major infection or a major illness in the frail elderly.

So what's the takeaway?

The mantra is change from baseline.

Any sudden change in behavior or function, you have to suspect a physical cause first.

Which leads us perfectly into segment three, barriers to care.

I mean, if the presentation is atypical, that's already a huge barrier.

But the text lists a whole host of other reasons why pain is so undertreated, starting with the patients themselves.

It's tragic, really.

We have a generation of older adults who pride themselves on stoicism.

They see pain as something you just bear.

They refuse to give in.

The whole stiff upper lip generation.

Right.

And coupled with that is fear.

They fear being labeled a complainer.

They fear addiction, which is a huge misconception we'll discuss.

And honestly, they fear what the pain means.

They worry that if they admit they are in pain, it implies a loss of ability.

It's the fear of losing their independence.

Like, if I tell them my hip hurts, they'll say, I can't live alone anymore.

They'll put me in a nursing home.

Exactly that.

They are trading pain relief for what they perceive as independence.

So they just suffer in silence.

And some even view pain through a spiritual lens as a punishment for past sins or just God's will, which makes them less likely to seek relief.

And then you have all the lack of a family support network and even provider barriers, lack of knowledge, or just plain stereotyping, or at least just grumpy.

And we have to talk about the consequences of this silence, of this under -treatment.

Unrelieved pain is not just about hurting.

It triggers a complete downward spiral.

The text mentions a cycle.

Pain leads to inactivity.

Right.

You hurt, so you stop moving.

You stop moving, so you get constipation and muscle atrophy.

Then you lose your independence, which leads to depression.

And depression actually lowers your pain threshold, so you hurt even more.

It's a vicious feedback loop.

It is a complete spiral.

One thing I saw listed as a consequence of pain that surprised me was incontinence.

How does that work?

Think about it functionally.

If your knees and hips hurt so much that it takes you five minutes just to get out of your chair, you aren't going to make it to the bathroom in time.

Oh, wow.

It's not that your bladder is failing.

It's that your pain is preventing you from ambulating quickly enough to get there.

So treating the pain could actually fix the incontinence.

Precisely.

You diagnose the real problem, the pain, and you fix the functional deficit.

Okay, so we know it's a problem.

We know why it's so often hidden.

Now, segment four,

the art of assessment.

How do we find it?

Well, the gold standard remains the patient's self -report, but you have to ask the right questions.

The text suggests the PQRSTU mnemonic.

I love the good mnemonic.

Let's run through it quickly.

P is for pattern.

When does it start?

How long does it last?

Is it constant or does it come and go?

Q is for quality.

This one's important.

Is it sharp,

dull,

burning,

throbbing?

These adjectives are clues.

Burning usually points to neuropathic pain.

Aching often points to nociceptive.

R is for relief or relieving factors.

Yeah, what makes it better?

Ice,

rest,

walking.

S is for stimulants.

What makes it worse?

Is it movement, eating, cold weather?

T is for timing and duration.

And U is for usage.

What have you used?

What worked?

What didn't work?

This prevents us from prescribing something they've already tried and failed with, which, you know, it builds trust.

It also reveals if they're taking over -the -counter meds we don't know about.

And beyond the history, there's the physical exam.

The text really emphasizes looking for nonverbal cues.

Absolutely.

Groans, bracing, guarding a body part, grimacing.

And we need to use standardized tools.

The numeric scale 0 to 10 is common, but it really doesn't work for everyone.

Right.

The text mentions the verbal descriptor scale -like.

No pain to too much pain.

Or the face's pain scale for those who might have language barriers or mild cognitive issues.

And I really like the visual of the pain diary that's included in the source.

It's not just about a number.

It tracks the time, the rating, what medicine was taken, any side effects.

It gives you a much better picture of the pain experience over days or weeks.

And we can't forget the functional assessment.

The CATS ADL scale.

Basically, does the pain stop you from eating, walking, or bathing?

And then there's the quality of life assessment.

The text suggests a question that I think is just beautiful in its simplicity.

How was life for you?

How was life for you?

That opens the door wide.

It does.

It allows the patient to tell you about the impact of the pain, not just the intensity.

I can't play with my grandkids anymore.

That tells you so much more than it's a six out of ten.

Now, this leads us to what I think is the biggest challenge in assessment segment five.

Cognitively impaired patients.

How on earth do you assess pain in someone with moderate to severe dementia who literally cannot tell you they are hurting?

This is where nursing becomes truly skilled observation.

It requires a detective's mindset.

And the text introduces a fantastic tool for this.

The Serial Trial Care Protocol, or STCP.

This seemed like a really systematic, logical approach.

It treats behaviors as signals.

Exactly.

In dementia, so -called bad behavior, pacing, fidgeting, combativeness, refusing to eat, is often just a cry for help.

It's a signal of an unmet need.

The STCT says, don't just medicate the behavior, find the cause.

So let's walk through the steps.

Step one is a physical assessment.

Right.

Look for an injury.

Look for infection.

Is there a pressure ulcer?

Is there a tooth abscess?

Is their diaper on too tight?

Are they sitting on their glasses?

You have to rule out the obvious physical irritants first.

If that's negative, step two is to check for effective or environmental needs.

Are they cold?

Are they lonely?

Is the room too loud?

Are they overstimulated?

You try to fix the environment.

Step three is a non -pharmacological comfort trial.

You try a warm blanket.

You try some soothing music.

You try a hand massage.

Simple comfort measures.

And if they're still acting out, step four.

This is the analgesic trial.

You assume pain is present and you give pain medication.

You start low, obviously, maybe with some Tylenol.

But the logic is this.

If you give them a pain reliever and the agitation stops, then the agitation was actually pain.

That is brilliant.

It's a diagnostic treatment.

It is.

And only if that fails do you move on to step five, psychotropics.

The key takeaway, the most important thing here is don't jump to sedating the patient

until you have ruled out pain using this protocol.

That is a total game changer for dementia care.

It reframes the whole interaction.

Okay, let's move to the medicine cabinet.

Step six, pharmacologic management.

The text has a golden rule here.

Start low and go slow.

But why?

What is happening biologically?

Well, it all comes down to pharmacokinetics.

How the body absorbs, distributes, metabolizes, and excretes drugs.

As we age, these systems all slow down.

Older adults have altered absorption.

Their livers, the body's detox center process drugs much slower.

Their kidneys, the filtration plant, excrete them slower.

So the drug just stays in the body longer.

Exactly.

Bioaccumulates.

A dose at a standard for a 40 -year -old could be toxic for an 80 -year -old because the previous dose hasn't fully cleared yet.

You get this dangerous stacking effect.

And the text references the WHO ladder.

It's a step -by -step approach.

It is.

Step one, non -opioids.

Step two, mild opioids.

Step three, strong opioids.

And there's a crucial note here.

Administer these around the clock.

Do not use PRN or as needed for persistent pain.

Why is that?

Why not just wait until it hurts to take a pill?

Because that creates a valley of pain.

If you wait until the pain is severe, you are always chasing it.

It takes much longer to get it under control.

If you take it on a schedule, you stay ahead of it.

You maintain a steady blood level of relief.

That makes a lot of sense.

So let's talk about the specific drugs.

First, non -opioids.

Acetaminophen, good old Tylenol.

First line for musculoskeletal pain.

It's generally safe, but you have to be so careful with the liver.

The maximum dose is 4 ,000 milligrams in 24 hours.

But you have to be careful because Tylenol is hidden in everything.

Oh, like in cold medicines?

Cold meds, sleep aids, combination pills like Percocet.

It's really easy to accidentally overdose if you aren't counting the total milligrams from all sources.

And what about NSAIDs?

Ibuprofen, naproxen.

I take these for headaches all the time.

For you, they are fine.

In geriatrics, we really dislike them.

Why?

What's the problem?

Well, they're effective for inflammation, but they're very risky.

They inhibit prostaglandins, which are chemicals that protect the stomach lining and support blood flow to the kidneys.

So in older adults, NSAIDs cause GI bleeding and ulcers, and they can easily push a person with borderline kidney function into full -blown renal failure.

The text explicitly says to avoid high doses or any long -term use.

Okay, good to know.

So moving up the ladder to opioids, these are for moderate to severe pain.

Right.

And older adults are very sensitive to them.

They get higher peak effects and a longer duration of relief from the same dose.

But we have to talk about the list of shame, the drugs to absolutely avoid.

Yes, that was in Table 14 -4, Mapparadine, which is also known as Demerol.

Avoid it completely.

It breaks down into a metabolite called Normaparadine.

This stuff accumulates in the brain and causes confusion, agitation, and even seizures.

It is a dirty drug for the elderly.

And the other one was Pentazocine or Talwin.

Also on the avoid list, it can cause CNS excitement and hallucinations.

Just don't use it.

Now, with opioids, everyone's first thought is addiction.

But the text highlights a different big enemy.

Constipation.

It is the most common and the most persistent side effect.

Nausea usually goes away after a few days.

Sedation usually fades in a day or two.

Constipation does not get better with time.

Opioids paralyze the gut.

So what do you do about it?

You have to be proactive.

We have a saying.

Mush and push.

Mush and push?

Yes.

You need a stool softener.

That's the mush.

And you need a stimulant laxative.

That's the push.

And you start them together.

You start this bowel program the same day you start the opioid.

Do not wait for them to get constipated because once an older adult gets impacted, it can be a true medical emergency.

That is a critical clinical pearl.

Mush and push.

I'm not forgetting that.

Finally, in the drug section, let's talk about adjuvants.

These are drugs that aren't technically painkillers, right?

Correct.

They are drugs designed for other things like seizures or depression that just happen to work really well on pain pathways.

This is where we get clever with our treatment plans.

Like gabapentin.

Gabapentin or Neurontin is an anticonvulsant, but it's fantastic for neuropathic pain.

That shooting nerve pain we talked about, it quiets down all that electrical activity.

And antidepressants.

How do they help with pain?

Well, triceclic antidepressants, or TCAs and SNRIs, they boost serotonin and norepinephrine in the brain, which actually help the body's own natural pain blocking pathways work better.

But you have to watch out for side effects like dry mouth and urinary retention.

For nerve pain, though, these can be miracle workers where standard painkillers have failed.

It's amazing how we can repurpose these tools.

Now, segment seven, non -pharmacologic and complementary therapies,

the integrative approach.

And the text really stresses using these with drugs, not just instead of them.

It's all about attacking pain from multiple angles.

So we have the basics, heat and cold.

Heat for stiffness and blood flow, cold for inflammation and spasms.

But you have to be so careful.

Older skin is thin and fragile.

You don't want to cause a burn or skin damage.

Then we have cognitive and behavioral stuff, imagery.

Yeah, visualization, taking the patient to a happy place in their mind using all five senses.

It might sound a little woo -woo, but it actually changes the brain's focus and can be very effective.

And simple distraction.

Music, puzzles, pet therapy.

If the brain is busy processing a puzzle or petting a dog, it has less bandwidth to process the pain signal.

It's a simple but powerful concept.

And then there are physical therapies like tennis units.

Transcutaneous electrical nerve stimulation.

Little electrical leads that you put on the skin and they create a buzzing sensation.

This relies on the gate control theory.

Okay, explain that simply for us.

Well, basically, your nervous system can only handle so much traffic at once.

The pain signal is traveling up a relatively slow nerve fiber.

The 10NS unit sends a buzzing sensation up a much faster nerve fiber.

Okay.

The fast signal gets to the spinal cord first and effectively closes the gate, blocking the slower pain signal from getting through to the brain.

That is fascinating.

It's like jamming the radar.

Exactly.

And massage works the same way.

It floods the sensory gates with non -pain information.

Let's bring all of this together with segment eight, a case study.

The text gives us the story of Mr.

K.

Right.

Mr.

K is a 77 -year -old with prostate cancer and bone metastasis.

And bone mets are incredibly painful.

He used to have a very active lifestyle, but now he's in nine out of 10 pain.

He's losing weight, he's immobile, and his wife is completely stressed out.

And here is the classic barrier we talked about.

He refuses opioids because he has a fear of getting hooked.

He saw his first wife suffer through cancer and he's terrified.

So the nursing plan has to start with education.

Addressing that addiction myth head on.

Right.

We have to explain the difference between addiction, which is a psychological craving and a loss of control, and physical dependence, which is just a physical reliance.

So dependence is expected.

Dependence happens to everyone.

If you're on these meds long enough and stop abruptly, you'll get withdrawal.

But addiction, true addiction, developing when opioids are used for genuine cancer pain is incredibly rare.

Then the dosing strategy.

You have to implement around -the -clock dosing.

He's in nine out of 10 pain.

You can't chase that.

You need a steady baseline to get him comfortable enough to even think about moving.

And of course, the side effects plan.

Start the mush and push immediately, the very first day.

Do not wait.

And finally, the goal setting.

Small, achievable goals.

Short walks with the dog, using a pain log to track his progress.

It's not about making him run a marathon.

It's about giving him his life back piece by piece.

It's a really comprehensive look at how complex this is.

It's not just take a pill.

It's psychology, it's physiology, family dynamics, and pharmacology all wrapped into one.

It really is the ultimate test of a nurse's skills.

So what does this all mean for us to summarize?

Pain is complex, it's subjective, and it is treatable.

But it requires a detective's eye, especially with dementia patients, and a scientist's caution with medications.

And it requires breaking that big myth we started with.

We have to stop accepting pain as a normal part of aging.

It just isn't.

Here's a final provocative thought to leave you with.

The text mentions briefly that for some elderly people, pain is seen as a metaphor for death, or even as an atonement for bad deeds.

It's a really heavy concept.

It is.

So the question for you to think about is this.

How does a nurse's ability to listen to the meaning of the pain

change the outcome of the physical treatment?

If you treat the body, but you ignore the spirit or the fear, are you really truly managing the pain?

That is the difference between curing and healing.

Something to mull over.

Thanks for joining us on this deep dive into gerontologic nursing.

Keep learning, keep questioning, and we'll see you next time.

Goodbye, everyone.

This has been the Last Minute Lecture Team.

Signing off.