Pain in Older Adults arthritis

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Myths vs. Facts
Pain in Older Adults
By Debra K. Weiner, MD

Pain is a common part of the lives of many older adults. Researchers estimate
that as many as one half of older adults who live independently and three-fourths
of those who live in nursing homes suffer from persistent pain, that is, pain that
does not go away.1 Most often, this type of pain is caused by arthritis, nerve
damage, and muscular problems.

What Can Be Done to Help Older Adults With Persistent Pain?

There are a wide variety of treatment options available to help older adults with
persistent pain. Unfortunately, health care providers often do not receive the
proper education regarding how to help older adults who suffer with persistent
pain. There are a lot of misunderstandings and myths about pain in older people.
The purpose of this article is to dispel some of these myths and give you some
basic information to take to your primary care provider so that you can get the
kind of help that you need.

Myth: Persistent pain is a normal part of aging.
Fact: While persistent pain certainly becomes more common as people age, it is
not normal to hurt. The presence of pain means that there is something causing
it. Sometimes the cause may be relatively simple such as muscular strain, but
sometimes it is more complicated, and an entire team of specialists such as pain
doctors, physical therapists, and psychologists may need to treat you to help you
to get better. Pain should never be accepted as normal.

Myth: Tests usually are needed to determine the cause of pain.
Fact: Often, health care providers order tests such as x-rays, MRIs and blood
tests to evaluate pain problems. Most of the time, however, these sorts of tests
are not necessary. Health care providers usually can determine and prescribe
the most appropriate treatment by talking with and examining the patient. If your
health care provider orders special tests, ask him or her how the results of the
tests will change the treatment he or she prescribes. X-rays and MRIs often are
ordered for older adults with low back pain. Many research studies, however,
have shown that these tests are not helpful because many of the same
"abnormalities" seen in patients with low back pain also are seen in people who
are pain-free.2 3 X-rays and MRIs often are more useful for determining what is
not causing a person's pain.

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Myth: Most persistent pain in older adults is caused by arthritis, so the
most sensible treatment is arthritis medications.
Fact: Arthritis is very common in older adults, but most people have evidence of
arthritis on x-rays but do not have pain. Muscular strain and irritation – known as
myofascial pain – also is extremely common in patients with a variety of
persistent pain conditions, but often is not recognized by primary health care
providers as a cause of pain. Diagnosing myofascial pain, which can be done
simply with a physical examination, is important because medications often are
not the most effective treatment for this condition. Muscle-related pain is treated
most effectively with various types of modalities administered by a physical
therapist such as heat, ice, gentle stretching, myofascial release techniques, or
electrical stimulation. Shots in the tight muscles known as trigger point injections
also might be helpful. These kinds of treatments have much fewer side effects
and less risk than most pain medications.

Myth: Older adults should not take opioids because of the potential for
Fact: Opioids, commonly known as narcotics, are strong pain medications that
may be necessary to treat severe pain. When used carefully, these medications,
including morphine, hydrocodone, oxycodone, fentanyl patches, and methadone,
can do a very good job of controlling pain without serious side effects. As with
any medication, patients who take these medications should be carefully
monitored by their doctors. Patients frequently express concern when their health
care provider suggests taking these medications because they fear addiction, but
this problem is quite uncommon. The word "addiction" means that patients
develop a psychological craving for medication even when they do not have a
physical need for it. Most older adults with persistent pain conditions have a real
need for pain medication, so the likelihood of becoming addicted is less than 1 in

Myth: Persistent pain in older adults is not likely to get better, so these
patients need to learn to live with it.
Fact: Actually, many effective treatments are available for most kinds of pain that
occur in older patients. Medications are only one small part of pain treatment.
The main goal of pain treatment is to maximize the patient's ability to be active
and engaged in life. Studies have shown that even though persistent pain usually
cannot be completely eliminated (that is, even with excellent treatment, pain that
is persistent is not likely to go away), patients can still enjoy significant
improvements in their function and quality of life.5 In other words, even if pain
treatment results in only a modest reduction in pain, it is still likely that function
and quality of life can improve significantly.

Myth: Activity is harmful in the older adult with pain.
Fact: Maintaining an active lifestyle is actually one of the major goals of pain
treatment. Patients with some types of pain, such as that associated with nerve

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damage (known as neuropathy), actually experience less pain when they are
active. Those with arthritis and muscular pain also benefit from activity. Often
patients ask, "How much activity is too much?" Typically the most accurate
answer to this question lies with the patient's own individual experience. Activity
that is followed by significant worsening of pain should be treated with rest the
following day, and probably less intense activity on a routine basis. Before
engaging in vigorous physical activity like running, biking, or fast-paced walking,
patients should get their doctor's approval.

Myth: Older adults with pain and depression will experience improvement
in their mood when their pain has improved.
Fact: Not necessarily. People with persistent pain often experience feelings of
sadness, irritability, and poor sleep. Sometimes these feelings improve when
pain improves. If these feelings are strong, however, it is important that they be
treated with antidepressant medications. If they are ignored, it may be more
difficult to treat the pain. In other words, pain and depression can become part of
a vicious cycle, and unless all parts of the cycle are addressed, neither pain nor
depression can be treated effectively.

Myth: As long as pain is not caused by cancer, it is not harmful.
Fact: Persistent pain, no matter what the underlying cause, can have a wide
range of effects on patients. Some of the more common include difficulty
performing activities of daily living like bathing, dressing, and cooking; depression
and anxiety; impaired appetite; difficulty concentrating; and trouble sleeping.
Patients with persistent pain also tend to make visits to emergency rooms and
doctors' offices more often than other people. So, persistent pain is not just an
inconvenience – it deserves to be treated aggressively and effectively.

Myth: If physical therapy previously caused worsening of pain, it should
not be prescribed in the future.
Fact: Nothing could be further from the truth. There are a wide variety of physical
therapy techniques, and a wide range of physical therapists with different training
and clinical experience. The best therapists from whom to seek treatment for
persistent pain conditions are those who have a lot of experience in treating
these conditions. If physical therapy is administered too aggressively or in not
quite the proper way, for example, patients may feel worse instead of better. This
is particularly true for certain types of muscular conditions and back problems. If
you have had physical therapy in the past and it was either not helpful or made
you worse, do not take this as an indication that physical therapy cannot help

Myth: If certain medications were tried before and didn't help, there is no
point in prescribing them again.
Fact: This is not necessarily true. Often, medications are prescribed incorrectly.
That is, the doses previously used may not have been high enough. Or, side
effects may have resulted if the dose was increased too rapidly. The decision

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about whether a medication should be tried again depends on the specific set of
circumstances of each patient, but as with other aspects of pain management
described above, it is important to remain open-minded about the possibility of a
positive outcome.

Debra K. Weiner, M.D., is associate professor of medicine, psychiatry and anesthesiology in the
division of geriatric medicine at the University of Pittsburgh School of Medicine and is Director of
the Older Adult Pain Management Program at the University of Pittsburgh Pain Medicine
Program. Dr. Weiner is the chief editor of Persistent Pain in Older Adults: An Interdisciplinary
Guide for Treatment and has written numerous journal articles on the subject. She is board
certified in internal medicine, rheumatology, and geriatric medicine and is a licensed
     1. Farrell, M. J.; Gibson, S. J.; Helme, R. D. Chronic nonmalignant pain in older people.
         Pain in the Elderly. Seattle: IASP Press; 1996. pp. 81-9.
     2. Weiner DK, Distell B, Studenski S, Martinez S, Lomasney L, Bongiorni D. Does
         radiographic oseoarthritis correlate with flexibility of the lumbar spine? Journal of the
         American Geriatrics Society 1994;42:257-63.
     3. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance
         scans of the lumbar spine in asymptomatic subjects - a prospective investigation. J Bone
         Joint Surg Am 1990;72(3):403-8.
     4. Porter J, Jick H. Addiction rare in patients treated with narcotics (letter). New Engl J Med
     5. Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-
         analytic review. Pain 1992;49:221-30.

Source: National Pain Foundation

                     Provided by Society of Certified Senior Advisors

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