ATrain Education


Continuing Education for Health Professionals

OR: Pain, Healthcare's Persistent Challenge, 6 units

Module 9

Pain in Special Populations

The extremes of age, as well as specific diseases such as cancer, provide special challenges to pain care. Infants and children, older adults, people with dementia, and cancer patients have little in common physiologically, but they share a propensity toward under-medication for pain. There is some evidence that the under-treatment of pain in these patient populations is improving, but acute care clinicians should pay particular attention to pain assessment and care in these patients (Thomas, 2013).

Pain in Infants, Children, and Adolescents

Although skepticism towards infant pain characterized much of the twentieth century, it is now well understood that an infant’s pain transmission pathways are fully developed by 22 to 24 weeks of gestation. In addition, pain inhibitory pathways are not fully developed in infants, suggesting that infants may feel even more pain than older children (Waxman et al., 2016).

In spite of its frequency, pain in infants, children, and adolescents is often underestimated and undertreated. It has been shown that infants and children who experience pain in early life show long-term changes in terms of pain perception and related behaviors (Srouji et al., 2010).

In infants, improper management of acute pain has been associated with negative short- and long-term consequences. Increased metabolic rate during painful experiences has been associated with increased potential for chronic pain, delayed wound healing, increased risk of infection, and alterations in pain sensitivity. Long-lasting consequences include delays in motor and brain development, as well as deficits in cognition and emotional regulation (Waxman et al., 2016).

In adolescents, headaches, stomachaches, or backaches are common complaints. These pain conditions commonly coexist and are more prevalent in girls and older adolescents. In an international survey involving 28 countries, although there was some variation in pain prevalence, there were no countries where these three pains were uncommon (Swain et al., 2014).

A Danish twins study found adolescents with persistent low back pain were 3.5 times more likely to have low back pain in adulthood. Co-occurrence of low back pain and headache in adolescence further increases the risk of developing future pain (Swain et al., 2014).

Barriers to pain management in children are numerous and include inaccuracies regarding pathophysiologic mechanisms of pain, fears regarding the use of pharmacologic agents, and deficits in knowledge of pain assessment. Personal values and beliefs also prevent adequate identification and alleviation of pain for all children (Srouji et al., 2010).


Did You Know . . .

Pain management in infants and children is an example of the influence of tradition, personal bias, persistence myths, and resistance to change. There is a substantial gap between evidence and practice, and some authors suggest that pediatric nursing, rooted deeply in tradition and ritual, is particularly resistant to evidence-based practice changes (Susan Lacey, 2008).


A significant percentage of children and adolescents (25%–33%) experience chronic pain, with prevalence increasing with age and occurring slightly more commonly in girls than boys. The most commonly reported locations of pain in children and adolescents are:

  • Head
  • Stomach
  • Arms
  • Legs (Carter & Threlkeld, 2012)

The most common chronic pain conditions in children include:

  • Migraine
  • Recurrent abdominal pain
  • General musculoskeletal pain (Carter & Threlkeld, 2012)

Chronic pain can interfere with developmental functioning, increase levels of emotional distress, and disrupt school attendance. Parents are also adversely affected and must negotiate appointments with multiple providers, including both primary and secondary providers. This can lead to missed school for the child, missed work for parents, and depletion of emotional and financial resources (Gorodzinsky et al., 2012).

Families faced with addressing their child’s chronic pain often report a loss of trust in providers when treatment fails to address the high levels of pain their child is experiencing. Parents express frustration with inconclusive medical tests, decreasing their hopes that any provider will be able to do anything for their child. With failure to reduce their child’s pain, parents may experience reduced expectations for treatment (Gorodzinsky et al., 2012).

A multidisciplinary approach using a biopsychosocial perspective to assess and treat chronic pain in children is effective in reducing the pain experiences and consequences of pain. Families note that providers in multidisciplinary settings displayed an interest in understanding the pain and increasing the comfort of the families during the appointment. Including the family’s perspective during treatment is an example of collaborative healthcare, which improves communication and more effectively implements the plan of care (Gorodzinsky et al., 2012).

Pain in Older Adults

Older adults have a high risk of experiencing daily pain and 20% report taking a painkiller regularly (Lillie et al., 2013). In older adults pain can produce unwanted consequences such as reduced quality of life, reduced engagement in social and recreational activities, and an increased risk of falls. Older adults with chronic pain conditions, such as back pain, are significantly less physically active compared with their counterparts who do not experience back pain (Ho et al., 2016).

Aging is associated with clinically important changes in pharmacokinetics and pharmacodynamics. Drug absorption is generally unchanged, but studies of drug distribution reveal increased plasma concentration of water-soluble drugs and increased half-life of fat-soluble drugs in older adults. For all opioids, half-life of the active drug and metabolites is increased in elders (Dalacorte et al., 2011).

Other issues that affect management of pain in older adults include:

  • Decline in the cognitive function
  • Low income
  • Co-morbid conditions and polypharmacy
  • Sedation, dizziness
  • Managing pain medications
  • Adhering to the prescribed schedule

Pain in People with Dementia

Pain is a very common problem in people with dementia: about 50% of people with dementia regularly experience pain. Pain in people with dementia pain can lead to neuropsychiatric symptoms and declines in cognitive functioning, as well as declines in the performance of activities of daily living. Next to neuropsychiatric symptoms, pain is the most cited reason for a decrease in quality of life in dementia. Therefore, recognition and adequate treatment of pain in people with dementia should have high priority (van Kooten et al., 2015).

There is evidence that people with advanced cognitive decline receive pain treatment, notably opioids, less frequently or in lower, insufficient doses as compared to their cognitively fit counterparts. Unable to properly communicate their pain, changes in behavior are often misinterpreted as behavioral symptoms, provoking inappropriate prescription of antipsychotics which, in turn, have been associated with compromised cognition, falls and fractures, and increased risk of death. The failure to accurately identify pain in cognitively impaired individuals is the primary cause of sub-optimal management of pain (Bauer et al., 2016).

While individuals with mild to moderate cognitive impairment are often able to report pain either verbally or by use of rating scales, these options are not available for those with advanced cognitive impairment, when the ability to communicate is severely impaired. As a result, self-reported pain may not always be reliable in people with advanced cognitive impairment and pain must be indirectly rated using a validated observational instrument. Various numerical and visual scales lack soundness in persons with cognitive impairment, due to their reliance on memory, abstract thinking, and speech comprehension (Bauer et al., 2016).

Among residents of nursing homes, it is estimated that 45% to 80% of residents have substantial pain that is undertreated. This suggests that when nursing home residents have moderate to severe pain, they have only about a 50% chance of obtaining adequate pain relief. Because cognitive impairment is common in many nursing home residents, assessing and managing pain can be particularly demanding. This often leads to both the underdiagnosis and undertreatment of pain (Bauer et al., 2016).

Pain at the End of Life

When a person is living with an advanced illness or coming to the end of life, preventing and relieving pain is often a high priority. Pain is among the most debilitating and feared symptoms faced by patients and their families. Despite this understanding, many severely ill patients spend the last days of their lives in moderate to severe pain.

Consistent assessment of pain is critical, as is involving the patient and family in establishing goals for palliative pain management. Patients and family members should be educated about dosing, compliance, addiction, tolerance, and side effects. Good pain management at the end of life involves listening to the patient’s subjective measure of pain, properly assessing patients with cognitive impairment, and overcoming myths about opioid therapy related to fear of causing addiction or hastening death.

Palliative Care

Palliative care is an approach that aims to improve the quality of life of patients and their families who are facing the problems associated with life-threatening illness. This is accomplished through the prevention and relief of suffering by means of early identification, assessment, and treatment of pain and other symptoms.

In 2013 the National Consensus Project (NCS) released updated guidelines for palliative care. The new guidelines are organized according to the following domains: structure and processes of care; physical, psychological, and psychiatric aspects of care; spiritual, religious, existential, and cultural aspects of care; care of patients at the end of life; and ethical and legal aspects of care. Clinical Practice Guidelines for Quality Palliative Care (3rd edition, 2013) is available at the National Consensus Project.

Cancer Pain at the End of Life

Undertreatment and inequitable access to pain treatment have been described among many cancer patients presenting with pain. The reported prevalence of moderate to severe pain in advanced cancer is approximately 64%, with a sharp increase to as high as 80% to 90% at the end of life (Gao et al., 2014).

A study evaluating the characteristics of patients with advanced cancer presenting to a palliative care service found the primary tumor as the chief cause of pain in 68% of patients. Most pain was somatic, and pain was as likely to be continuous as intermittent (NCI, 2016).

Musculoskeletal Pain at the End of Life

Although palliative care has in the past focused on cancer, it has recently expanded to include other conditions, including musculoskeletal pain at the end of life. Population-based studies indicate that musculoskeletal pain is such a common and significant issue at the end of life that musculoskeletal disease may have as much, if not more, effect on whether a person dies in pain than the condition that is the cause of death (Lillie et al., 2013).

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