Undertreatment for cancer pain is a concern for elderly people, and special attention is needed to make sure that treatment is complete and effective.

The problem is two-fold. First, many elderly cancer patients have concerns and convictions that can prevent them from receiving and accepting the pain relief they need. Second, some health care professionals harbor significant misconceptions about treating pain in the elderly, resulting in inadequate care and suffering.

Whatever the cause of undertreatment for pain, the consequences can be harsh. Pain causes suffering, whether an individual is fully alert and functioning, or troubled by cognitive problems. Lessening pain restores hope for increased strength and the ability to heal in all of us, regardless of age.

Elderly Patient Concerns

Without question, some elderly people are reluctant to seek relief for their cancer pain. These are some of the misconceptions and beliefs that may be at the heart of this problem:

• The belief that pain is just an inevitable part of having cancer, and of aging;
  
• The desire to be "a good patient" translates into not mentioning pain or other discomforts;
  
• Fear that taking medications, especially opioid medications, will cause drug addiction;
  
• Fear that "too much" pain medication will shorten life;
  
• Fear of being too much of a problem for the children and other caregivers;
  
• Fear that physicians won't focus on curing the cancer if they spend energy treating the pain;
  
• Fear that worsening pain means worsening disease, and perhaps impending death;
  
• Fear that being in pain will prevent going home from the hospital;
  
• Fear of being so "drugged" that there will be no decent quality of life;
  
• Fear that side effects from pain medications will be worse than the pain.
  
• Fear that they will have no way to pay for the medications to treat the pain.

Fortunately, all of these concerns can be addressed — but they must be recognized and accepted as a reality for elderly people. Family members and the health care team should understand these concerns may be present, and work together to alleviate the fears that underlie them. For more information on addressing these concerns, see Understanding Pain: The Basics.

For information on managing the expense of pain medications, see Understanding Pain: Financial Considerations.

Health Care Professional Concerns

Some health care professionals, notably those who have had little experience in pain management for the elderly, have a tendency to undertreat and even ignore the presence of pain in older patients. A central misconception is that the elderly "cannot tolerate" opioid medications, which are a frontline defense against cancer pain. The result is that the elderly are not given the right medications or medication of sufficient effectiveness to really manage their cancer pain. If you, as an elderly person in pain, or as a family caregiver, believe that pain is not being properly and completely treated, it is time to insist on the help of a pain management expert.

The nursing home dilemma. Problems of pain management in the elderly can be of particular concern when the patient is a nursing home resident. A recent study of more than 13,000 nursing home patients with cancer showed that nearly one-third of these patients experienced pain daily, and one in four received no pain medication at all.

Family and friends of nursing home residents with cancer must be especially attentive to the possibility of cancer pain, and make certain to have this pain appropriately treated. If the staff at the nursing home is unwilling or unable to do this, seek outside assistance from pain experts…and never accept the statement that "nothing more can be done" to relieve the elderly person's pain.

Facts About the Elderly and Pain

Managing cancer pain in the elderly is different than managing it in a middle-aged or younger person, for a variety of reasons. But what is most important to remember is that pain in the elderly is, in fact, manageable — and it must be treated. Every person with cancer has a right to be as free from pain as possible, and to have a reasonable quality of life.

• Elderly people process medications at a different, usually slower pace than do younger people. This means that health care professionals must understand this, assess each patient's circumstances and choose medicines and dosages of those medicines that are appropriate. Some health care professionals use the term "stronger and longer" as shorthand to describe how older people usually react to pain medications. Translated, this means a medicine's impact is stronger on this population, and it takes longer for an older person's body to eliminate the medication from the body.
  
  
• The elderly may have more kinds of pain than cancer pain — and may be taking medications already to treat these other sources of pain. Many elderly may have pain from one or more of disorders like arthritis, osteoporosis, diabetes side effects, angina, gall bladder conditions, back pain and more. If you are taking medications for conditions like these, it is very important to let your health care providers know about this, because these other medications can cause problems if they are not either halted or taken into account when a cancer pain relief plan is developed.
  
  
• Levels of pain in the elderly may vary more frequently within a day than is usually seen in younger people. This means more frequent assessment of pain may be needed to maintain good pain control.
  
  
• Keeping track of medications — pain medications and others — can be more challenging for elderly people, especially if there is memory loss or other cognitive problems present. Medication management is a very important issue, and if the person being treated is experiencing difficulty with this, another solution must be found. Sometimes elderly people will put off taking their pain medications until the pain is excruciating. If this is accidental, perhaps due to the need to take multiple medications and not due to significant cognitive problems, the problem can be eased by the use of special pre-filled medication dispensers or the use of medication calendar to keep track of doses and schedules.

Assessing Pain

Pain assessment is a critical part of developing a comprehensive pain management plan for everyone with cancer pain, including the elderly. Some special awareness is needed:

• If the elderly patient has no cognitive problems or any other difficulties in understanding, the same pain measurement scales used for other adults can be used. These are described in Managing Cancer Pain: The Basics/Pain Assessment Scales. And, of course, conversation about pain is also an important part of understanding the presence of pain.
  
  
  • If a person with no previous signs of cognitive problems suddenly develops these, it may be necessary to change to a different pain medication, or alter the dose of medication given. However, don't give up efforts to manage the pain.
    
    
• The health care team must know all medications a person with cancer is taking, both prescription medications and over-the-counter drugs, not only for cancer but for any other health condition that may be present. Medications used to manage cancer pain can and will interact with other medicines, and in creating a care plan, all medications a person takes must be factored in. If herbs, vitamins, gels, pain creams and other similar products are being used, the health care team needs to know about these, too.
  
  
• Many elderly people experience some measure of hearing and vision difficulty. These can impair communications if they are not known and understood. If you have problems seeing and hearing, it is very important to let your health care team know this.
  
  
• If the patient is experiencing memory loss and difficulty in understanding what is said, then the health care team will need to use other approaches. Family members can be very helpful in assisting the health care team in seeking to understand what the patient is communicating:
  
  
  • Try talking first. Sometimes patients will be able to communicate more than initially thought if the questioner is patient.
    
    
  • Ask about pain more than once, and in more than one way. Some questions may elicit more responses than others.
    
    
  • Don't assume that the absence of overt, physical signs of pain mean that there is no pain. Instead, assume there is likely to be some pain, and consider providing pain relief and then reassessing outward behavior. Is there less grimacing, protecting of a part of the body, and irritability than before the medication was given?
    
    
  • Family caregivers of elderly patients with cognitive impairment (or who are frail) in a nursing home or other residential facility should make a particular effort to monitor the patient's well-being and to look for signs of unmanaged or undermanaged pain. Daily attention is best, if this can be arranged.
    
    
• If a person is frail, other considerations become important:
  
  
  
  • Health care providers should never assume that being physically frail means a person is also cognitively impaired!
    
    
  • If you are elderly and frail, make sure your health care team does not speak to you as if you were experiencing comprehension problems. Correct them promptly.
    
    
• If an elderly person is very ill or in severe pain and English is not his or her primary language, the ill person may revert to speaking that primary language. If a reminder to speak English doesn't work, an interpreter will be needed.

Medications

For more detailed information on pain medications and how they are given, please see Treating Pain/Medications.

• NSAIDs and Acetaminophen
  
  
  • The most common side effect of NSAIDs in the elderly is gastrointestinal problems, such as stomach irritation, ulcers and bleeding. For some people, some newer NSAIDs, called Cox-2 inhibitors (Vioxx and Celebrex, for example) may be less irritating to the stomach.
    
    
  • In general, for elderly patients, acetaminophen (Tylenol) is a better choice than most NSAIDs, as acetaminophen does not usually cause gastrointestinal problems. However, the maximum daily dose of acetaminophen is 4 grams every 24 hours.
    
    
  • Aspirin, because it is most likely to cause gastrointestinal problems, is not a recommended choice for pain management in the elderly.
    
    
  • Other NSAIDs, such as ibuprofen and naproxen, can sometimes be used, but should generally be given at low doses and sometimes with an additional medication to protect the stomach.
    
    
  • As with all medications, NSAIDs and acetaminophen can be slower to leave the body of an elderly patient than a younger one. This pace of clearance may also be affected if the patient is taking multiple other medications.
    
• Opioids
  
  
  
  • Like NSAIDs and acetaminophen, opioid medications taken by elderly people can have a more powerful impact, and be slow in exiting the body.
    
    
  • In general, elderly people who begin to take opioids should be given a reduced amount of a standard dose. If more medication is needed to relieve pain, it should be given slowly, gradually increasing as the patient is able to manage it.
    
    
  • Elderly people, like all who take opioids, will have to cope with constipation as a side effect. They should be instructed in ways to manage this at the same time the opioid medication is started. Preventing constipation is easier than treating it.
    
    
  • There are a number of opioids that can be used successfully with elderly patients. However, short-acting medications that can cause dizziness and imbalance, like propxyphene (Darvon), should be avoided. Another relatively short-acting medication that should not be given is meperidene (Demerol). If your health care team suggest using these medications for anything other than short-term pain, such as that which might be felt during a brief procedure, register your concern about side effects and overall effectiveness.
  
  
• Adjuvant Medications
  Adjuvant medications are those originally created for a purpose other than pain management but are also effective in treating pain. These medications can be given with NSAIDs, acetaminophen or opioids, or used by themselves. As with other medications, adjuvant medications should be started at a low dose and gradually increased as needed. Also, talk with the health care team about possible side effects from different adjuvant medications, so these are not a surprise of they occur.

For a listing of adjuvant medications and their purposes, see Treating Pain: Medications.

Non-Medical Treatments to Relieve Pain

In general, most other techniques to help relieve cancer pain can be successfully used by the elderly — especially heat, cold, massage, imagery, distraction and relaxation. For detailed information on these approaches, please see Treating Pain: Non-Medical Treatments to Help Relieve Pain.

For Caregivers

1. Ask hospital, outpatient and nursing home health caregivers what medications, in what doses, and with what frequency are being administered to treat your relative's cancer pain. Develop a written list with each medication's name, dose and time it should be taken.
   
   
2. Ask why these medications were chosen, and who selected them.
   
   
3. Monitor the comfort level of your loved one, and let the health care team know how well the treatment prescribed is managing pain. (The elderly may need to have their pain assessed more than once a day.)
   
   
4. Learn the names and dosages of all medications (prescription and over-the-counter) that your family member takes, and the reasons for which they were ordered. Make certain the health care team has this information
   
   
5. For ease and convenience, consider keeping medical information, including medical history, procedures, treatments, medications and doses and times in a folder or binder.

Questions for Your Doctor

1. How will we treat my cancer pain? How does my age influence my treatment plan?
   
   
2. What medications will be used?
   
   
3. What if the medication I'm given doesn't work well? Can more be done?
   
   
4. I've had stomach disorders from taking some over-the-counter pain medicines before. Does this mean I shouldn't take them now?
   
   
5. I don't want to be so drugged by medicine that I can't live my life. Can we avoid that and still relieve my pain?
   
   
6. I know pain medications are likely to cause side effects. How will we manage these?
   
   
7. I take medications for other health care problems. Will I have to stop taking them, or take less of them, if I use cancer pain medications? What impact will this have on me?
   
   
8. If I have difficulty managing my medications and other treatment, who should I call for immediate assistance?
   
   
9. Why am I taking a medicine called an antidepressant for my cancer pain? I'm not depressed.
   
   
10. How long will I have to take pain medication?
    
    
11. Will techniques other than medicine be used?
    

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