The problem of pain in old age

This comprehensive literature review examines the complex problem of pain in the older population, highlighting that aging predisposes individuals to the occurrence of chronic and debilitating pain. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, being a complex and subjective phenomenon that can significantly limit physical, mental, and social activities.

Pain can be classified in several ways. With regard to duration, it is divided into acute (less than three months, not related to age) and chronic (more than three months, more frequent in older adults). Chronic pain can be nociceptive (resulting from stimulation of pain receptors) or neuropathic (resulting from damage to the nervous system). The involutional changes that occur in the older organism, combined with multiple chronic diseases characteristic of this age group, mean that approximately 85% of older adults suffer from pain.

Diseases of the locomotor system are the main causes of pain in older adults, affecting about 80% of the population over 70 years. They include osteoporosis, osteoarthritis, and rheumatoid arthritis. Osteoporosis causes sudden pain in the thoracolumbar region due to vertebral fractures. In rheumatoid arthritis, the pain is chronic and intensifies with basic activities.

In osteoarthritis, it results from the pressure of structural changes on the neurovascular bundle.

Depression represents another important geriatric problem related to pain, affecting approximately 15% of the population over 65 years. It frequently manifests as masked depression, with chronic pain in areas innervated by the sacral, brachial, sciatic, intercostal, and cranial plexuses. The relationship between depression and pain is bidirectional, creating a 'vicious cycle' in which poorly treated chronic pain leads to depression, which in turn intensifies the perception of pain.

Pain assessment in older adults is particularly challenging, especially in patients with cognitive impairment and depression. Subjective scales such as the verbal and numerical rating scales are used, in addition to questionnaires such as the McGill-Melzack Pain Questionnaire. In patients with dementia, it is crucial to observe objective signs such as worsening appetite, teeth grinding, grimacing, agitation, and resistance to care.

Treatment should be multimodal, combining pharmacological and non-pharmacological methods. Acetaminophen is the first-choice medication and may be combined with weak opioids. Nonsteroidal anti-inflammatory drugs should be used with caution due to multiple side effects in older adults. Adjuvant medications such as antidepressants and anticonvulsants are useful in neuropathic pain.

Among non-pharmacological methods, physical rehabilitation, occupational therapy, psychological therapy (especially cognitive-behavioral therapy), and complementary therapies such as acupuncture stand out. The maintenance of independence and functional capacity is crucial for older adults, since even small improvements in functional activity can significantly improve pain control.

The study emphasizes the importance of awareness among older adults, family members, caregivers, and healthcare professionals that pain is not an inherent attribute of aging and can be adequately diagnosed and treated. Unfortunately, in clinical practice, inadequate treatment or absence of treatment of pain in older adults is frequently observed, representing a significant public health problem that requires a systematic and multidisciplinary approach.