Pain: Healthcare's Persistent ChallengePage 10 of 21

8. 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 under-treated. 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 an international survey of pain in adolescents, almost three-quarters of adolescents experienced headache, stomachache, or backache at least monthly. These pain conditions commonly coexist and are more prevalent in girls and older adolescents. While there was some variation in pain prevalence across the 28 countries surveyed, there were no countries where these three pains were uncommon (Swain et al., 2014).

In adolescents, pain is an important predictor of future pain. 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).

Chronic Pain in Children

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 often report a loss of trust in providers when treatment fails to address the high levels of pain their child is experiencing. Parents may experience 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

Pain is the number one complaint of older adults and 20% report taking a painkiller regularly. Establishing the prevalence of pain in older adults has been difficult, however, because of variations in pain study parameters and definitions (Lillie et al., 2013). Wide variations in prevalence exist in the literature due to differences in the studies, including country and date of study, type of study, population studied, type of pain examined, pain definitions used, sites of pain examined, methods used, and time period of prevalence examined (Age and Ageing, 2013).

Older adults, because of their elevated chronic disease burden, have a high risk of experiencing daily pain, and their pain experience may produce a wide spectrum of unwanted consequences including reduced quality of life, reduced engagement in social and recreational activities, and an increased risk of falls. The presence of pain also reduces the likelihood for older adults meeting physical activity guidelines even when factoring in chronic health conditions. 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).

Because of these difficulties, pain is a persistent and costly problem in older adults, raising several potential issues associated with pain management. Physiologic and cognitive changes, medical literacy, low income, co-morbid conditions, and adherence affect the success of a pain management program.

Issues with Pain Management in Older Adults

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).

Decline in the cognitive function is also an area of concern with aging adults, partly because impaired cognitive function can lower medication literacy. This has been associated with a decrease in the likelihood of reading prescription leaflets or other medication information, a reduction in medication reconciliation (agreement between physicians and patients on what medications are currently being used), patients misinterpreting dosage directions on drug labels, and failure to adhere to verbal counseling by physicians (Taylor et al., 2012).

Older adults with low income, those without adequate prescription drug coverage, and those using high-cost medications are likely to stretch out their medication supply by skipping doses or extending the interval between doses. Taking a lower-than-prescribed dose is especially prevalent in patients taking multiple medications, those prone to medication side effects, and people who resist prescribed treatment due to personal or cultural beliefs.

In older adults with multiple co-morbid conditions, polypharmacy is common and increases the risk of adverse drug reactions, nonadherence, and cost. Several drugs used to treat pain, such as opioids, tricyclic antidepressants, gabapentin, and pregabalin, are among those associated with sedation, dizziness, and falls, particularly in frail or vulnerable elders (Dalacorte et al., 2011).

Managing Adherence

About 20% of community-dwelling adults aged 65 and older take ten or more medications daily. This is a critical issue because polypharmacy has been associated with a higher risk of non-adherence to treatment. Adherence is the extent to which a patient’s actual drug regimen—dosage, time, and mode of administration—corresponds to the prescriptions made by the doctor. In older people, poor adherence has been reported in 26­% to 59% of cases (depending on the population considered and on the definition of adherence used), and is associated with a decline in clinical status, a greater risk of falls, hospitalization, and death, as well as an increase in health expenditures (Bilotta et al., 2011).

The main barriers to adherence in older adults are:

  • Forgetting to take the drug
  • Limited organizational skills
  • Belief that the drug is ineffective or unnecessary
  • Cost (Bilotta et al., 2011)

Managing pain medications is a serious problem for caregivers, who may be required to manage multiple medications, may have difficulty keeping prescriptions filled, and may miss giving doses due to their work schedules. A substantial number of community-dwelling older adults do not recall receiving any instructions on taking their medications and rely on family members or caregivers for help.

In regards to pain management, following the prescribed treatment plan is important for the prevention and control of pain. If opioids are part of the plan of care, healthcare providers should discuss any fears related to side effects and risk of addiction. Family members and patients must be encouraged to tell healthcare providers when they are experiencing pain or when the nature or level of pain changes. Although complete pain relief may not be possible, providers can assure patients and family members that they will work to keep pain at a level that allows patients to engage in activities necessary to recover and return home.

Adherence can be improved by providing additional training for caregivers of older adults who are unable to take their medications properly. Providers can support caregivers by routinely reviewing their patients’ medications to ensure that drug regimens are adequate, are being followed, and as simple as possible. There is evidence that better adherence can be obtained if patients and caregivers are engaged in decisions about starting, keeping, or changing a medication. With frail older adults, their desire for involvement is essentially fulfilled by good communication, which does not necessarily extend to the decision-making process (Bilotta et al., 2011).

Pain in People with Dementia

Pain is a very common problem in people with dementia. Its prevalence is high; there is good agreement in both large and small studies that about 50% of the people with dementia regularly experience pain. This is not surprising, considering that advanced age is an important risk factor for developing pain (van Kooten et al., 2015).

Pain in people with dementia is associated with neuropsychiatric symptoms, 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).

Pain in Nursing Home Residents

Because cognitive impairment is common in many nursing home residents, assessment and management of pain can be a particularly demanding problem. Communication difficulties in people with cognitive decline leads to both the under-diagnosis and under-treatment of pain (Bauer et al., 2016).

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 run the risk of being 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. There is broad consensus that the failure to accurately identify pain in cognitively impaired individuals is the primary cause of sub-optimal management of pain (Bauer et al., 2016).

In 2009 the American Geriatric Society recommended a comprehensive, disease-specific assessment to establish adequate pain management on an individual level. 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 applicable 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 should be indirectly rated using a validated observational instrument. Various numerical and visual scales are available for self-reported experience of pain, all of them lacking soundness in persons with cognitive impairment, due to their subjection on memory, abstract thinking, and speech comprehension (Bauer et al., 2016).

Pain at the End of Life

Pain control for cancer and palliative care is used when pain and symptom control is important for quality of life. An integrated model of care to address the entire patient, body and mind, is the best approach. This may serve as a bridge to hospice care.

Oregon Pain Guidance, 2016

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. Effective pain management is important for many conditions and 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.

From a provider perspective, 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 issues.

In 2013 the National Consensus Project (NCS) released updated guidelines for palliative care. The guidelines build upon and expand the definition of palliative care developed by the Centers for Medicare and Medicaid Services. The updated guidelines state, “The goal of palliative care is to relieve physical, psychological, emotional, and spiritual suffering and distress of individuals and families (recognizing family as it is defined by each individual).”

The main tenets of the National Consensus Project guidelines are as follows:

  • Palliative care centers on the unique goals, strengths, and needs of each patient and family.
  • An interdisciplinary team—including, but not limited to, chaplains, nurses, physicians, and social workers with expertise in palliative care—provides services in a collaborative manner.
  • The team strives to promote continuity of care across various settings and providers.
  • Equitable access to palliative care and the availability of palliative care from the time of diagnosis onward is essential.

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

Cancer Pain at the End of Life

Under-treatment 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).

The traditional mainstay of pain management since the 1980s has been the World Health Organization’s three-step “ladder” approach, involving recommendation of a single strong opioid for moderate to severe cancer pain. Increasingly over the treatment course, patients may be switched (sometimes called rotated) from one opioid to another because of side effects or concerns regarding effectiveness of the initial opioid. In addition, patients may be prescribed combinations of opioids, usually when they are receiving long-acting and short-acting compounds or compounds by different routes, especially if one compound is not available in the required formulation or route (Gao et al., 2014).

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).

Gender Differences in Pain Sensitivity

Evidence suggests men and women experience and report pain differently (Horn et al., 2014). Specifically, women have been shown to have a lower pain threshold and pain tolerance and stronger responses to analgesics than do men. These differences are present in community-dwelling and clinical samples. It is often difficult to discern whether well-documented differences in pain reports among women and men are biology based (sex) or shaped by social and cultural expectations (gender) (Ho et al., 2016).

Evidence suggests that differing biologic and psychosocial factors may account for gender differences in pain sensitivity. It is well-known that psychosocial factors can influence the perception and evaluation of pain. One commonly studied psychosocial factor is pain-related fear, which includes fear of the sensation of pain, fear of movement or re-injury, and fear of physical activities that are assumed to cause pain. Pain-related fear may contribute to the shift from acute low back pain to chronic low back pain, and numerous studies have demonstrated the association of pain-related fear with disability in patients with chronic and acute low back pain, hip and knee osteoarthritis, and foot and ankle dysfunction (Horn et al., 2014).

The differences in psychosocial factors (such as pain-related fear) may contribute to differences in the pain reports between men and women. Several lines of research using experimentally induced pain have begun to shed light on these sex differences. For example, an experimental pain study using electrical stimuli found the increased pain experienced by women during a movement task was accounted for by higher reports of fear among women compared to men. In addition to pain-related fear, Robinson and colleagues found women to be more willing to report pain and consider themselves to be more sensitive to pain compared to males. Conversely, some males believe that they have higher pain endurance than women and as compared to the typical male (Horn et al., 2014).

Clinically, gender differences are relevant because a greater percentage of chronic pain sufferers are women. Women also generally report more areas of bodily pain and more pain-related disability compared to men. Given that pain is such a prevalent and debilitating condition with serious health and economic consequences, the Institute of Medicine has stressed the need to improve healthcare delivery of pain management, including individualized treatment approaches (Horn et al., 2014).