Pharmacologic Pain Management in the Elderly Cancer Patient

Patricia M. Clark, MSN, RN, CS, AOCN®

Introduction

Pain management continues to be a primary concern for cancer patients, their
families, and oncology nurses. At least 90% of cancer patients report at
least moderate pain at some time during the course of their disease, and at
least 42% of elderly cancer patients have reported unrelieved pain.[1] The
elderly cancer patient is the norm rather than the exception, because at
least half of all cancers are diagnosed in patients over the age of 65
years.[2] The number of people over 65 years old in the United States is
expected to reach 64.3 million by 2030,[3] making it inevitable that the
problem of pain management for cancer patients will become more prevalent.
Oncology nurses were urged at the 26th Congress of the Oncology Nursing
Society to "Look Before You Leap!"[2] when managing pain in the elderly
cancer patient.

Who Is "Old"?

How do we know when we are old? Definitions of old have traditionally
started at age 65 years. People in the 65- to 75-year age group are usually
termed the "younger old"; those in the 75- to 85-year age group are the
"older old," and those over 85 years of age are termed the "oldest old" or
"elite old."[4] All these groups are expected to increase in size. The 2000
US census reported 4.2 billion citizens older than 85 years.[5] It has been
predicted that by 2050, 1.2 million people will be alive at 100 years of
age.[2]

The Problem of Pain in the Elderly

Pain is not an uncommon symptom in the elderly. Trouble with pain has been
reported by 25% to 50% of elders living in the community[6] and in as many
as 80% of nursing home residents.[7] What makes pain in the elderly
different from pain in other cancer patients? Jeannine Brant, RN, MS, AOCN®,
Oncology Clinical Nurse Specialist and Pain Consultant at Saint Vincent
Hospital in Billings, Montana, and Rita Wickham, RN, PhD, AOCN®, Associate
Professor of Nursing and Clinical Nurse Specialist in Pain and Palliative
Care at Rush-Presbyterian St. Luke's Medical Center in Chicago, Illinois,
answered this question in their presentation.[2]

Barriers to Pain Control in the Elderly Cancer Patient

Patient beliefs about pain can be barriers to management. Geriatric cancer
patients may have a desire to be "good patients," or may regard pain as just
another part of aging. They may be afraid that admitting to pain will take
the clinician's focus away from more critical health problems. Fear of
addiction to opiates and passive acceptance of pain as part of a cancer
diagnosis also contribute to inadequate pain control in this population. The
perception of clinician apathy also prevents patients from reporting pain.
As Wickham stated in the presentation, "Patients don't want to be seen as
bothersome or hypochondriacal so they don't tell us [about pain] sometimes.
If they get an apathetic response from their physician or nurse...and we
tell them in our words or in our actions that 'well, you have to live with a
little pain' they are much less likely to tell us again that they do have
pain. On the other hand, if they perceive that their caregivers respect
their reports of pain, they will probably be much more likely to tell
us."[2]

Cultural Influences

Culture can play a big role in attitudes about pain control and palliative
care. In some cultures, there can be a mistaken notion that palliative care
is given only immediately before death and that the clinician has "given up"
on the patient.[8]

Dona Maria: A Case History

In a session on cultural influences in palliative care, Guadaloupe Palos,
RN, LMSW, DPh(c), Cancer Project Specialist, Department of Anesthesiology
and Critical Care at the University of Texas, MD Anderson Cancer Center,
Houston, Texas, used the example of Dona Maria, a 54-year-old
Mexican-American woman with metastatic breast cancer to the bone. She had
extreme pain in her back and hip that was unrelieved by self-care measures.
Dona Maria had trouble using the 0 to 10 pain scale to describe her pain
because she was accustomed to using descriptors. She explained to clinicians
that she knew she was going to die very soon, and she showed them a picture
of her coffin and invited them to her funeral. She believed that her
suffering would end when she died.
The staff thought that Dona Maria was ready to talk about palliative,
end-of-life care because she had showed them pictures of her coffin.
Unfortunately, when the staff approached this subject, the patient and her
family assumed that her care team was giving up. After careful
investigation, it was determined that Dona Maria was not taking her pain
medication because she felt it would not help. She believed that a
neighbor's curse had doomed her to constant pain. Dona Maria asked her
healthcare team to bless her house so that she would feel comfortable dying
at home. Once the blessing was complete, Dona Maria felt her pain decrease
and agreed that perhaps her disease was also causing her pain. She gradually
accepted the pain team's efforts to treat her pain.

Clinician Cultural Education

Palos explained that through the Priority Pain Relief Education for Minority
Outpatients (PREMO) program at MD Anderson Cancer Center, clinicians learned
that pain might be at a level 9 or 10 before some patients will notify the
clinician because they didn't want to be perceived as complaining or
bothering the provider. In both African Americans and Hispanics, the
concepts of "being strong" and "not leaning on pain medications" can be very
important. While it should be remembered that not all members of an ethnic
group share the same beliefs, it is equally important to ask about beliefs
regarding pain and its treatment.[8]

Other Barriers to Pain Control

Brant explained that family members who think that pain is part of the aging
process or that it may be related to worsening disease also can be barriers
to pain control. Family members may also hesitate to bring up pain control
because they don't want to "distract" the clinician from treating the
cancer, or they may fear addiction.[2]
Clinician bias may be caused by age bias that has not been dispelled by
education in geriatric care. Some clinicians overestimate the extent of
adverse reactions to pain medication and believe that elderly clients cannot
accurately report their pain if they are cognitively impaired. Clinicians
may think that a patient who can sleep and be distracted can't possibly be
in pain.[2]
Healthcare systems may unknowingly erect their own barriers to pain control
in the elderly cancer patient. Lack of standard assessments of geriatric
patients, inadequate treatment protocols, and fragmented care are a few of
the institutional barriers that may block effective pain management in
geriatric cancer patients. The Joint Commission for Accreditation of
Healthcare Organizations (JCAHO) has implemented pain standards that may
overcome some of these barriers and establish consequences for poorly
managed pain.[9]

Influence of Age on Pain Assessment

Just as there are patient, family, clinician, and institutional barriers to
pain control, there are barriers to pain assessment. In general, the same
principles of assessment used for younger patients should be used for
cognitively intact elderly patients. However, it is important for the
clinician to allow additional time when assessing the elderly. As with any
assessment, a quiet, private place will help the clinician obtain an
accurate history, as will optimizing communication by making sure that the
patient's hearing aids are working and that dentures and glasses (if worn)
are in place during the interview.[4]
Pain presentation may be different in the elderly. The location of the pain
may be affected not only by cancer but also by other chronic conditions.
When assessing pain severity, the usual 0 to 10 pain scale may be shorted to
a 0 to 5 scale for ease of use. The faces scale may also be used to rate
pain.[2] This scale uses pictures of facial expressions to rate pain.
Assessment should include quality of pain and aggravating and alleviating
factors. If analgesics have been used, the clinician should ask about their
effectiveness and any adverse events experienced. Most important, a list of
all current medications (both prescription and over-the-counter) should be
obtained. The elderly client should also be assessed for depression or other
affective responses to pain.
Psychosocial concerns include where the patient lives and with whom, the
presence or absence of a caregiver, and the extent of caregiver burden. This
is especially important in elderly couples when a partner who is older than
the patient is trying to provide care.
Examination of the painful part of the body should include functional
assessment, if appropriate. This assessment may include gait and balance,
motor strength, peripheral sensation, and cranial nerves.

Cognition in the Elderly

Cognitive impairment is a primary concern for healthcare providers who
assess and treat pain in the elderly. Delirium and dementia are common
syndromes of cognitive impairment in the elderly, but they have different
causes and manifestations (Table 1).

Table 1. Comparison of Delirium and Dementia

Characteristic
Delirium
Dementia
Onset
Acute
Insidious
Course
Fluctuates
Steadily progressive
Consciousness/orientation
Clouded/disoriented
Clear until late stages
Attention/memory
Inattention/poor short-term memory
Attentive/poor short-term memory
Psychosis
Common
Less common
The risk for delirium increases in terminally ill patients and puts patients
at risk for mismanagement because of communication difficulties. Risk
factors for delirium include [2]:
*         Dementia
*         Advanced age
*         Infection/sepsis
*         Hospitalization
*         Isolation in unfamiliar surroundings
*         Surgery
*         Myocardial infarction
*         Congestive heart failure
*         Acute blood loss
Cognitive impairment does not alter an elder's ability to state that they
have pain and indicate its location. Use of simpler pain scales (0 to 5) and
the faces scales may be easier for the cognitively impaired patient.
Additional time should be given for a response. If the patient is nonverbal,
look at behavioral indicators, especially the classic furrowed brow as a
sign of pain.[2]

Choosing Medical Interventions for Pain Control in the Elderly

When choosing medications for pain relief in the elderly, the American
Geriatric Society has suggested the following guidelines[10]:
*         Use the least invasive route to give medication.
*         Start low and go slow.
*         Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with
caution due to side effects; acetaminophen is the drug of choice for mild
pain.
*         Opioid analgesics are effective for relieving moderate to severe
pain.
*         Adjuvant medications are appropriate for certain pain syndromes.
*         Pharmacologic therapy is most effective when combined with
nonpharmacologic approaches.
Brant and Wickham emphasized the effects of physiologic changes associated
with aging on drug metabolism. Kidneys become smaller with age, and there is
decreased blood flow contributing to decrease in glomerular filtration rate.
The liver becomes smaller as functional tissue is replaced by fat. Effects
on the liver and kidney may be exacerbated by disease, treatment, or
environmental factors. The half-life of drugs and their toxic effect may be
extended, depending upon kidney and liver function.
The route of administration of drugs may also be affected by aging.
Decreased saliva may hamper swallowing, and injections may be difficult to
give due to decreased muscle mass. Oral drugs may be poorly absorbed due to
changes in stomach acidity. Lipid-soluble drugs may have delayed onset and
accumulate, while water-based drugs may have early peak and onset of action.

Effects of Age on Common Analgesics

Brant explained the effects of aging on common classifications of analgesic
drugs using the World Health Organization analgesic ladder from the Agency
for Health Care Policy and Research (AHCPR) guidelines.[11]
NSAIDs. NSAIDs are protein bound. Since older patients have more fat than
protein and lower serum albumin levels, serum NSAID levels will be higher,
producing a higher incidence of side effects. When bone and/or joints are
involved, NSAIDs may be useful but gastrointestinal prophylaxis is
important, especially in NSAIDs with a low cyclo-oxygenase (COX)-2/COX-1
inhibitor ratio. Examples of these drugs include naproxen, indomethacin, and
piroxicam. NSAIDs with a high COX-2/COX-1 ratio include etodolac, meloxicam,
celecoxib, and rofecoxib. These drugs have fewer gastrointestinal side
effects. Patients on NSAIDs should be monitored for side effects, and
electrolytes should be drawn 2 weeks after the initiation of therapy and
intermittently thereafter to monitor renal function.[12]
Opioid analgesics. Opioid analgesics are useful in the elderly, but certain
drugs should be avoided. Avoid agonist-antagonist preparations, merperidine,
and propoxyphene, which have active metabolites and are central nervous
system stimulants. Opioids should be started at doses 25% to 50% lower than
those given to young adults due to high fat-to-protein ratios. There is
increased sensitivity to the peak effect of short-acting opioids in the
elderly, so it is advantageous to stabilize pain with long-acting
medications and give lower rescue doses. Rescue doses should be 5% of total
daily dose and should be given every 4 hours.[12]
Morphine is a useful opioid in the elderly, but care must be taken in the
event of renal insufficiency. Metabolites M3G and M6G can accumulate in this
setting and cause excitation of the central nervous system and myoclonus, as
well as an increase in the usual side effect of sedation.[2] Oxycodone has
no toxic metabolites and is a preferred opioid in the elderly because of its
short half-life and the availability of both short- and long-acting
forms.[2]
Transdermal fentanyl is also a preferred opioid in the elderly. Patients
seem to like the idea of a patch, and there is anecdotal evidence suggesting
that constipation is less common with this drug and dosage form.[2] However,
the drug should not be used in opioid-naive patients or in patients with low
serum albumin or recurrent infections. Toxicity may result from increased
uptake from the skin reservoir or from increased free drug.[12] The
half-life of this drug is longer; 50% of the drug remains in the skin
reservoir 24 hours after patch removal.
Hydromorphone is also useful in the elderly. It has no known toxic
metabolites, high solubility, and a short half-life. Under close
observation, it can be used to convert a patient who has had toxic effects
from other opioids. [2]
Methadone is the least expensive of the opioids but is not recommended for
use in the elderly because it has a long and variable half-life, multiple
drug-drug interactions, and can cause sedation, confusion, and delirium.[2]
Adjuvant pain medications. Adjuvant medications for pain relief include
tricyclic antidepressants, anticonvulsants, and benzodiazepines. Tricyclic
antidepressants (imipramine, doxepin, clomipramine, desipramine,
nortriptyline) may be used to treat neuropathic pain as well as sleep
disturbance. In the elderly, it is suggested that the dose begin at 10 mg
orally at bedtime and be titrated to a therapeutic level (50 mg to 150 mg in
divided doses).[12] These drugs can cause orthostatic hypotension and
cardiovascular side effects (atrioventricular heart block), so patients
should be monitored carefully.[2]
Anticonvulsants used as adjuvant pain medications include gabapentin,
carbamazepine, and phenytoin. These medications are used to treat
neuropathic pain. Gabapentin is preferred in the geriatric population
because it has few side effects, but it still may increase sleepiness and
dizziness and cause ataxia and peripheral edema.[2] While benzodiazepines
can be used as adjuvant drugs for pain relief, in older patients they often
cause sedation and patient falls and they tend to mask rather than relieve
pain.[2]

Cost of Pain Management in the Elderly

Medicare currently does not cover the cost of oral pain medication, which
poses an economic burden for seniors who are on limited, fixed incomes. Many
seniors try to save money by using mail-order pharmacies (which are
sometimes mandated in managed care environments), but there can be delays in
receiving medication that compound the problem of pain control. While some
opioids are cheaper than others (methadone is cheaper than morphine), the
least expensive drug is often not the drug of choice for elderly cancer
patients.[2]

Clinical Practice Implications

Brant and Wickham reminded their nursing colleagues that, "Oncology nurses
must be diligent, astute, and persistent to meet the needs of the elderly in
pain."[2] Pain control in elderly cancer patients continues to challenge
oncology nurses. Pain is twice as likely to be present in cancer patients
over the age of 60 years.[2] In addition to pain, the elderly cancer patient
experiences physical and cognitive changes that are part of the aging
process. While cognitive impairment and agitation are often blamed on
analgesic intake, they are actually more likely to be related to pain.[2]
Pain assessment in the elderly is a complicated process requiring patience
and focus. The oncology nurse must take into account physiologic changes in
metabolism, absorption, and excretion of drugs when suggesting pharmacologic
methods of pain control. Consistent monitoring for relief of pain and
adverse effects of pain medication is essential to providing quality care
for the elderly patient.

References

1.      Cleeland CS. Undertreatment of cancer pain in elderly patients.
JAMA. 1998;279:1914-1915.
2.      Brant JM, Wickham R. The challenges of pain assessment and
management in the elderly: look before you leap. Program and abstracts of
the 26th Congress of the Oncology Nursing Society; May 17-20, 2001; San
Diego, California. Discussion Session.
3.      Gliford DM. The Aging Population in the Twenty-First Century:
Statistics for Health Policy. Washington, DC: National Academy Press; 1988.
4.      Duthie EH. History and physical examination. In: Duthie EH, Katz PR,
eds. Practice of Geriatrics. 3rd ed. Philadelphia, Pa: WB Saunders and Co;
1998.
5.      US Government Census 2000. Available at:
http://www.census.gov/prod/cen2000/dp1/2kh00.pdf. Accessed May 26, 2001.
6.      Ferrell BA. Pain management in elderly people. J Am Geriatr Soc.
1991;29:64-73.
7.      Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am
Geriatr Soc. 1990;38:409-414.
8.      McCarthy HC, Powe BD, Palos G, Simpson MR. The influence of culture
on palliative care. Program and abstracts of the 26th Congress of the
Oncology Nursing Society; May 17-20, 2001; San Diego, California.
Instructional Session.
9.      Joint Commission on Accreditation of Health Care Organizations. Pain
standards for 2001. Available at: http://www.jcaho.org/standard/pm.html.
Accessed May 26, 2001.
10.  American Geriatrics Society Clinical Practice Committee. Management of
cancer pain in older patients (clinical practice guidelines). J Am Geriatr
Soc. 1997;45:1273-1276.
11.  Agency for Health Care Policy and Research. Management of cancer pain.
AHCPR Publication No. 940-592; 1994.
12.  Abrahm JL. Advances in pain management for older adult patients. Clin
Geriatr Med. 2000;16:260-311.


Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.