Recurrent pain
Professor Trisha Dunning AM
Chair in Nursing and Director Centre for Nursing and Allied Health
Research, Deakin University and Barwon Health, Australia
Case history
Mr XY has long standing type 2 diabetes and he requires
insulin
He has erectile dysfunction and cardiovascular disease
Generally he is able to take good care of himself, but he
requires some assistance to administer his insulin
because his ‘eyesight is not what it used to be’
He drives short distances to the shops and to visit family
His HbA1c 12 months ago was 9% (75mmol/mol)
Mr XY presents with painful burning and tingling in his
feet that keeps him awake at night
Lives at home with his wife who helps with his insulin
administration
Mr XY has not visited his doctor or other health
professional for 12 months
Key points about pain in older people
Pain is :
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common in older people
often undertreated
usually multifactorial in origin
always subjective
Pain may be acute or chronic, the prevalence of chronic pain
steadily increases with increasing age
Persistent pain of long duration is often associated with
psychological and social consequences including depression and
compromises the ability to perform usual activities of daily living
(ADLs)
Older people may not report severe, chronic or excruciating pain
Key points about pain
Pain originating from chemical, mechanical or thermal
stimulation of peripheral receptors is likely to respond to:
• non-opioids
• non-steroidal anti-inflammatory (NSAIDS)
Pain originating from damage to the peripheral or central
nervous system may respond to centrally acting medicines such
as:
• Tricyclic antidepressive and anticonvulsive agents
Psychological pain is often present and is harder to detect an
quantify. Mr XY might be concerned about his erectile
dysfunction and the effects on his sexual health and wellbeing.
Assessment
Undertake a thorough history, physical examination and psychological evaluation and
evaluate the functional status, adherence to medicines, nutrition and fitness to drive
Check renal and liver function, metabolic status, vitamin B12, vitamin D and folate
Undertake a thorough medication review and ask about side effects and
complementary/herbal medicine use
Pain history and assessment of Mr XY:
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What the pain means to him
Where the pain is, when it occurs, how long it lasts
The symptoms
Effect on sleep
What prescribed and self-prescribed treatment he has tried and their effectiveness
Whether he has had any falls
Undertake a thorough foot assessment and neurological review of both feet
Consider other cause of neuropathic pain such as alcohol-induced vitamin B12
deficiency
Management plan
The management plan should be developed with Mr XY and his wife
to ensure their goals are met
Unnecessary or ineffective medication should be stopped.
Analgesics should be prescribed while considering Mr XY’s renal and
liver status as well as the risks and benefits to Mr XY of relevant
analgesic medicines and potential interactions with his existing
medicines.
Pain management strategy:
• Start with simple analgesia and/or recommended first line tricyclic, anticonvulsive
or NSAIDs e.g. Gabapentin 300-600 mgs/day
• Generally avoid medicines with a long half life
• Taking medicines on a regular dose schedule often results in better analgesia than
taking analgesics ‘as needed’
• Consider non-medicine option instead of/in addition to analgesics
• Exercises within Mr XY’s capacity
Management plan
Refer Mr XY to a podiatrist for advice about appropriate foot wear and to a
diabetes educator for foot self-care education
Plan to manage any concomitant conditions such as depression and anxiety
Consider whether testosterone replacement could improve energy and wellbeing
Review blood glucose targets. Mr XY’s last HbA1c was 75mmol/mol, reducing it to
around 64mmol/mol could contribute to pain management and help improve
mood as well as reduce the risk of infection.
Consider Mr XY’s need for support and determine whether any community
services are likely to be beneficial
Mr XY may need to stop driving OR develop a proactive plan to stop driving
Develop a plan for regular foot assessment and metabolic review
Key points for clinical practice
Pain is common in older people but the causes and
consequences of pain are complex
Likewise, pain assessment and management is complex and
must be personalised and holistic
Peripheral neuropathy and other neuropathies are common
causes of pain in older people
Pain is likely to have more than one underlying cause
Chronic pain may cause/exacerbate depression and reduce
quality of life and sleep quality
Advanced care planning should be considered