Pain Experience of the Elderly

Method 

A descriptive research study design was used to investigate the pain experience of the elderly living in the community. Permission to conduct the study was obtained through the University and Medical Center Institutional Review Board at a university located in the southeastern United States. One hundred twenty-four undergraduate nursing students enrolled in a gerontology nursing course collected the data for this study as part of their learning experiences associated with the study of pain assessment of the elderly. Students received instructions on how to conduct the research following guidelines on the protection of human subjects. A script was used by each student to obtain permission to conduct the interview session and collect the data. Each student was responsible for selecting one study participant, obtaining informed consent, and interviewing the participant. Participants were informed that the interview was voluntary, they could stop at any time, they could elect to not answer any or all questions posed, and that confidentiality would be maintained without their name being included in any written documentation. Participation in the interview constituted the participant's willingness to participate. The sample consisted of individuals who were aged ≥60 years, spoke English, remained relatively independent in function (lived at home or in assisted living residences), and were willing to participate in the study.

Results 

A convenience sample of 124 meeting inclusion criteria participated in the study. Table 1 describes the characteristics of the study participants. Participants were primarily between 71 and 90 years of age, female, high school graduates, and living at home.

Table 1. Demographic Characteristics of Participants (N = 124)

		n	%
	Age at interview, y
	60-70	7	5.6
	71-80	49	39.5
	81-90	58	46.8
	91+	10	8.1
	Gender
	Female	94	75.8
	Male	30	24.2
	Education
	Less than high school	36	29.0
	High school graduate	60	48.4
	Attended college or higher	28	22.6
	Residence
	Home	91	73.4
	Assisted living facility	33	26.6

Table 2 describes the pain characteristics of the study participants. Over 75% of the participants reported their pain to be in the musculoskeletal regions of the body, and >80% of the participants reported their pain as moderate or severe. Ten participants did not have any pain during the month preceding their interview, and another eight reported their worst and average pain as mild. Over 60% of the participants reported experiencing pain only occasionally, and morning and evening was the time of the day when the pain experience was worst. Of those participants categorized with severe pain, 45% of them experienced continuous pain, compared with 19% of those reporting moderate pain (p < .01). The predominant pain descriptors used by those reporting moderate or severe pain were aching, throbbing, and tiring-exhausting. There were no statistically significant associations between any of the demographic variables and pain severity.

Table 2. Pain Characteristics of Participants (N =124)

		n	%
	Location of pain
	Muscular-skeletal	92	74.2
	Other	13	10.5
	GI	5
	Cardiac/circulatory	4
	Head	3
	All over	1
	Muscular-skeletal + other	9	7.3
	Cardiac/circulatory	3
	Head	3
	All over	3
	No pain	10	8.1
	Severity of pain
	None/mild	18	14.5
	Moderate	68	54.8
	Severe	38	30.6
	Frequency of pain
	Occasional	82	66.1
	Continuous	32	25.8
	No pain	10	8.1
	Worst pain period
	Morning	41	33.0
	Afternoon	10	8.1
	Evening	33	26.6
	Night time	21	16.9
	All the time	9	7.3
	No pain	10	8.1

Participants were asked to indicate how much their pain interfered with several life activities during the month preceding their interview. Table 3 lists these activities, the proportion of participants reporting high pain interference on the activities, and the difference in high pain interference occurrence between participants experiencing moderate or severe pain. For the total group, the activities experiencing the greatest pain interference were walking, general activity, mood, and enjoyment of life. The rate of high pain interference of those with severe pain was significantly higher than those with moderate pain on general activity, mood, sleep, enjoyment of life, and relations with people. Although only 4% of those with moderate pain reported that pain interfered with their enjoyment of life, this interference rate increases to >34% in those with severe pain.

Table 3. Participants with Moderate and Severe Pain Reporting High Pain Interference

	Activity	Total (n = 106)		Moderate Pain (n = 68)		Severe Pain (n = 38)
		n	%	n	%	n	%
	General Activity	23	21.7	6	8.8	17	44.7∗
	Mood	19	17.9	6	8.8	13	34.2∗
	Walking	38	35.8	19	27.9	19	50.0
	Sleeping	15	14.2	4	5.9	11	28.9∗
	Enjoyment of life	16	15.1	3	4.4	13	34.2∗
	Concentration	10	9.4	3	4.4	7	18.4
	Relationships	8	7.5	1	1.5	7	18.4∗

∗ p < .007 (Bonferroni adjusted level of significance).

Table 4 shows the treatments identified by moderate and severe pain respondents that made their pain better. About one-half of them reported that medication or inactivity made their pain better (including 16% who reported both medication and inactivity). There was no difference in the reported effectiveness of medication and activity by those with moderate or severe pain. However, the use of heat or cold was reported significantly less often as an effective pain treatment with those with severe pain compared with those with moderate pain. When asked what makes their pain worse, >80% of those with moderate or severe pain identified that activity made their pain worse. Interestingly, 10.1% of those who reported that activity made their pain worse also reported that exercise made their pain better. The medications used most often for pain relief were over-the-counter nonsteroidal antiinflammatory drugs and prescription opioid pain relievers. Alternative treatments included biofeedback, chiropractic use, support hose, and emollients.

Table 4. Treatments Reported to Be Effective by Participants with Moderate and Severe Pain

	Treatment	Total (n = 109)		Low Pain (n = 68)		High Pain (n = 38)
		N	%	N	%	N	%
	Medication	51	48.1	33	48.5	18	47.4
	Inactivity	51	48.1	33	47.1	19	50.1
	Heat/cold	30	28.3	26	38.2	4	10.5∗
	Exercise	17	16.0	11	16.2	6	15.8
	Alternative	17	16.0	14	20.6	3	7.9

∗ p < .01 (Bonferroni adjusted level of significance).

Discussion 

The results of the present study indicated that 85% of elderly participants experienced moderate (discomforting or distressing) or severe (horrible or excruciating) pain in the month preceding their interview, and that >28% of those with moderate or severe pain experienced continuous pain. For the individuals in this study sample, the interference of their pain experience on their life activities was not overwhelming. For those experiencing moderate pain, <5% reported that their pain had a high level of interference on their enjoyment of life. Even among those experiencing severe pain, only 34% reported that their pain had a high level of interference on their enjoyment of life. Regardless of how much pain interference experienced by these individuals, there is strong evidence of inadequate pain management. No information was collected on whether the study participants were receiving treatment from health care professionals for their pain nor on the extent of friends or care-givers in their pain management.

Inadequate pain management was quite evident in the present sample. Phillips (2000) has reported that inadequate attention to pain control is unethical, clinically unacceptable, and wasteful in terms of cost. Landi et al. (2001) concluded that a failure to make all reasonable efforts to treat pain successfully should be considered as one of the most important indicators of poor-quality health care. In spite of the fact that the American Geriatrics Society Panel on Persistent Pain in Older Persons (2002) has developed guidelines to assist health care professionals in providing effective pain management to maintain the client's dignity, functional capacity, and overall quality of life, persistent pain in the elderly continues to be a significant problem.

The predominant pain experienced by the present sample was musculoskeletal pain. The location and intensity reported correspond to earlier research done by Cowan (2002) and Dunn and Horgas (2004), in which respondents on average rated the pain as moderate in intensity and occurring in four body locations (hips, legs, knees, and ankles). Buckwalter (2003) has proposed that pain associated with aging and musculoskeletal disorders will increase in future generations.

The subjects reported medications and inactivity as the predominant strategies used to make their pain better. Although the importance of exercise in providing a number of health benefits has been established, less is known about the role exercise plays in relieving pain in older adults (Koltyn, 2002). However, Hakkinen (2004) found that after 2 years of a strength-training program, subjects experienced a 67% decrease in pain and a 50% decrease in limitations in daily activities. Improvements in osteoarthritis pain also after an exercise program have been demonstrated (Koltyn, 2002). In addition, pain with walking may be intensified, but the movement in water aerobics may be therapeutic. While many of the subjects in the present study reported that inactivity made their pain better, the consequences of inactivity can result in additional problems for the elderly.

The participants in this study used a variety of modalities to alleviate their pain symptoms, including the use of nonsteroidal antiinflammatory drugs, antiinflammatory drugs, alternative measures, analgesics, and emollients. Oral medications were the predominant method of pain relief. Although pharmacologic strategies are effective, research indicates that physiologic changes in the elderly may alter the effectiveness of pharmacologic interventions owing to altered absorption rates or altered stomach pH (Davis & Srivastava, 2003). It has been effective to combine pharmacologic and nonpharmacologic therapies (home remedies, massage, topical agents, and heat/cold applications) for relief of chronic pain in the elderly (Davis & Srivastava, 2003). The present study shows that these methods were not found to be as useful as medication and inactivity for pain relief.

A paucity of research exists on controlled trials for evaluating the effectiveness of many nonpharmacologic approaches to pain management (Harris, 2007). Research on alternative and complementary therapies has found that massage therapy can be useful in reducing stress and pain in the elderly (Trombley, Thomas, & Mosher-Ashley, 2003) and that foot massage increases blood circulation, promotes relaxation, and stimulates endorphin secretion, resulting in a reduction of pain and anxiety (Jirayingmongkoi, Chantein, Phengchomjan, & Bhanggananda, 2002). Lansbury (2000) found that elders wish to be active in their treatment plan and given choices in addition to conventional treatments of medication, exercise, and physiotherapy. The focus in the treatment of pain should be improved physical function, as well as enhanced quality of life (Weiner, 2007).

Conclusions 

Unfortunately, pain is a common occurrence in the daily life of the community-dwelling elderly. The present research supports findings of earlier studies and reiterates the significance of the problem of underrecognized and undertreated pain in the elderly. The consequences of chronic pain are multidimensional and significant; problems such as depression, social isolation, sleep disturbance, decreased ambulation, decreased enjoyment in life, and altered social relationships result as elders live with pain. Patients and health care providers alike need to evaluate their assumptions about pain. Patients should be encouraged to report their pain, and those who care for them need to understand that the treatment of pain is a serious concern at any age. It is imperative that health care providers work with the elderly and their families to alleviate the fears that are associated with pain and pain treatments to assist them to have an enhanced quality of life, good functional capacity, and effective pain management. Clinicians must stay abreast of new knowledge and treatments in the rapidly changing field of medical science as new pharmacologic and nonpharmacologic strategies are identified. The findings of the present study strengthen the call for health care providers to recognize the scope of the problem and the importance of seeking effective strategies to manage pain and enhance the quality of life in the elderly. There are definitely challenges to be faced in providing effective management of pain in the elderly; however, these challenges are not insurmountable. Every person, regardless of age, has the right to be as free from pain as possible.