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ISSUE NO 6 3 NEWS & REVIEWS PAIN IN THE AGING PATIENT Professor Hans Georg Kress The treatment of pain in the elderly poses particular problems. Due to changes in metabolism and an increasing risk of adverse effects to drugs, treatment in this group may require a different approach. The prevalence of pain is known to increase with age. Whilst back pain is the common pain type in the population in general, a particularly increased rate of chronic pain due to joint pain or arthritis is common in older age groups. The incidence of neuropathic pain has also been shown to be especially high in the elderly patient1 . The results of the National Health and Wellness Sur- vey (NHWS) indicated that older women seem to suffer more than their male counterparts. In the studied population, approximately 70% of females over 65 reported to have experienced pain in the last month compared to 35% of males in the same age group2 . Under-treatment of pain in the elderly It is commonly believed that if an older person does not complain, they do not have pain. However, there are many reasons why elderly may be reluctant to complain, de- spite the fact that pain significantly affects their functional status and mood. Due to dementia or commu- nication problems and the difficulty of using pain assessment scales, many older people are unable to convey to health providers the true extent of their symptoms. Further- more, the elderly frequently have insufficient dosing and increased adverse effects, especially in poly- medicated patients. The NHWS indicated that pain sufferers in general tend to utilize healthcare resources at greater levels than non-sufferers and this increases with age. Elderly patients require more healthcare provider visits, especially specialist consultations. There are also social implications with an associated need for more provision of care and support in the home. Choices for analgesic treatment in the elderly It has been reported that 18% of elderly people take analgesic me- dications on a regular basis3 . Of these, 71% take prescription anal- gesics and 72% OTC preparations. The use of non-selective NSAIDs in elderly patients is associated with a risk of gastrointestinal impairment, renal impairment, hypertension, and platelet dysfunction. Selective COX-2 inhibitors maybe conside- red in preference for use in this age group, although there is con- cern for their use in patients with increased cardiovascular risk. The use of opioids is problematic due the sensitivity of older persons to their analgesic properties and also the side effects (especially con- stipation). Age-related changes in metabolism may lead to problems with prolonged half-life and also changes in pharmacokinetics of opioids. Despite these factors, due to the association of incidence of atypical pain presentations and may also misinterpret the physical sensations they are experiencing. Many older people harbour false beliefs about pain and its manage- ment and may be reluctant to seek advice, believing that rest is the best method of pain relief. The re- sulting immobility can cause mus- cle atrophy and osteoporosis with an increased likelihood of injury resulting from falls. Untreated pain causes sleep deprivation, depres- sion and mood disturbances, all of which have a negative effect on quality of life. The challenges of the geriatric patient Increasing age is associated with a physiological decline in the functio- ning of the renal, hepatic and im- mune system. Other age-related changes include a decreased vo- lume of distribution as a result of a decrease in mean body weight, decreased activity of some drug- metabolizing enzymes, and redu- ced serum protein concentration. These factors, combined with the higher incidence of co-morbidities such as hypertension, raised cho- lesterol and diabetes requiring the use of multiple medication, increase the risk of adverse ef- fects and problems with complex drug interactions. There is a deli- cate balance between the risk of under-treatment versus toxic side effects. Cognitive impairment, par- ticularly memory loss, can affect compliance resulting in overdose,