Aging: Are these 4 pain myths complicating care?

Abstract

Is pain a natural part of aging? Does "toughing it out" make pain more tolerable? Read on to see what the evidence really says regarding 4 common misconceptions about pain and aging.

Treatment guidelines, recent reviews, and a growing body of evidence emphasize the importance of pain assessment and management in older adults.¹ Yet pain in this patient population remains markedly undertreated.² Beliefs about pain in later life, held by many providers as well as patients, often act as a barrier to adequate treatment. Through a process known as stereotype embodiment, widely held misconceptions about the inevitability of pain among older patients influence expectations, cognitive function, health practices, and autonomic responses.³

Beliefs about aging itself can also have dramatic consequences, both positive and negative. In one longitudinal study, those who had positive self-perceptions of aging when they were 50 had better health during 2 decades of follow-up and lived, on average, 7½ years longer than those who had negative self-perceptions at the age of 50.⁴

Although little research has focused specifically on pain-related stereotypes held by older adults, their importance has long been recognized. Twenty years ago, a review found that the failure to incorporate older patients’ beliefs about pain could have a negative effect on pain management.⁵ And in 2011, an Institute of Medicine report found a critical need for public education to counter the myths, misunderstandings, stereotypes, and stigma that hinder pain management in patients across the lifespan.⁶

We set out to identify widely held stereotypes that older adults and physicians have about pain—and to report on primary studies that support or refute them. We focused on noncancer pain. In the pages that follow, we identify 4 key stereotypes that misrepresent the experience of older adults with regard to pain, and present evidence to debunk them.

Stereotype #1: Pain is a natural part of getting older

Chronic pain is often perceived as an age-related condition. In in-depth interviews, older adults with osteoarthritis reported pain as a normal, even essential, part of life. As one patient put it, “That’s how you know you’re alive … you ache.”⁷

Among primary care patients with osteoarthritis, those older than 70 years were more likely than younger patients to believe that people should expect to live with pain as they get older.⁸ And more than half of older adults who responded to a community-based survey considered arthritis to be a natural part of getting old.⁹

Physicians, too, often view pain as an inevitable part of the aging process, giving patients feedback such as “What do you expect? You’re just getting older.”¹⁰

Are they right?

Is pain inevitable? No

In fact, chronic pain is common in older adults, occurring in more than half of those assessed, according to some studies.¹¹ In addition, some epidemiological studies have found an age-related increase in the prevalence of pain,^12-14 with older age predicting a more likely onset of, and failure to recover from, persistent pain.¹⁵ But numerous studies have failed to find a direct relationship between pain and age.

A National Center for Health Statistics report found that 29% of adults between the ages of 45 and 64 years vs 21% of those 65 or older reported pain lasting >24 hours in the month before the survey.¹⁶ And a meta-analysis comparing age-related differences in pain perception found that the highest prevalence of chronic pain occurred at about age 65; a slight decline with advancing age followed, even beyond the age of 85.¹⁷

Chronic pain disorders are less frequent. In fact, many chronic pain disorders occur less frequently with advancing age. Population-based studies have found a lower prevalence of low back, neck, and face pain among older adults compared with their younger counterparts;¹⁶ evidence has also found lower rates of headache and abdominal pain.¹⁸ Other epidemiological studies suggest that the prevalence of musculoskeletal pain generally declines with advancing age,¹⁹ and a study of patients in their last 2 years of life found pain to be inversely correlated with age.²⁰ These findings refute the stereotype that advancing age inexorably involves pain, and challenge the notion that pain in later life is normal and expected, and unworthy of treatment.

Stereotype #2: Pain worsens over time

Some patients and physicians expect that as people age, their pain will increase in intensity. In one study of community-dwelling older adults, 87% of those surveyed rated the belief that more aches and pains are an accepted part of aging as definitely or somewhat true.²¹ Indeed, patients of all ages have expressed the belief that older age confers greater susceptibility to, and suffering from, painful conditions like arthritis.²² Many common causes of pain in older adults, especially osteoarthritis, are seen as resulting from degenerative changes, which worsen over time.²³

Does pain intensify? Not necessarily

Some studies have linked older age to a worse prognosis for patients with musculoskeletal pain, but a greater number have found that aging has no effect on it.²⁴

Pain does not always progress. In a large cohort of patients with peripheral joint osteoarthritis, radiographic joint space narrowing worsened over 3 years, but this did not correlate consistently with worsening pain.²⁵ When the same cohort was assessed after 8 years, there was significant variability in pain, with no clear progression.²⁶

FAST TRACK

Migraine pain, as well as low back, neck, and facial pain, is less common among older adults that it is among their younger counterparts.

In another study involving older patients with restrictive back pain, the pain was frequently short-lived and episodic and did not increase with age.²⁷ And in a population sample in Norway, the mean number of pain sites decreased slightly over 14 years in those older than 60 years, while increasing in those aged 44 to 60.²⁸ Another study of patients with knee osteoarthritis identified factors that were protective against a decline in pain-related function: These included good mental health, self-efficacy, social support, and greater activity—but not younger age.²⁹ The enormous heterogeneity in both the experience and the course of pain suggests that age-related pain progression is neither universal nor expected—and contradicts a purely biological paradigm in which pain inevitably worsens over time.

Stereotype #3: Stoicism leads to pain tolerance

Some patients believe that the inability to deal with pain is a sign of being soft or weak, and that a “tough it out” approach makes pain easier to tolerate.⁷ In one survey, older adults were more likely than their younger counterparts to express such stoicism, frequently agreeing with statements like, “I maintain my pride and keep a stiff upper lip when in pain,” “I go on as if nothing had happened …,” and “Pain is something that should be ignored.”³⁰

Unfortunately, some physicians reinforce such attitudes, telling older patients, in effect, that they’d better “get used to it.”¹⁰ And family and friends may make it worse. Patients taking opioids reported that it wasn’t unusual for those close to them to view their use of these analgesics as a sign of weakness.³¹

Does stoicism help? Probably not

Older adults seem less likely than younger adults to label a sensation as painful, suggesting a more stoic approach in general.³⁰ While some research has found that nociception—the perception of pain in response to painful stimuli—decreases with advancing age,³² other studies have found the opposite.³³ And population-based studies focusing on the consequences of pain indicate that it continues to have powerful negative effects, especially depression and insomnia, in older patients.

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In one study of patients with peripheral joint osteoarthritis, progressive joint narrowing did not correlate consistently with worsening pain.

The degree of pain experienced is more strongly associated with depression in older patients compared with younger adults,³⁴ and greater pain reduces the likelihood that depression will improve with treatment.³⁵ Pain also continues to interfere with sleep. In one national sample, 25% of those with arthritis said they suffered from insomnia, roughly twice the prevalence of insomnia found in those without arthritis.³⁶ In another study, individuals with arthritis were 3 times more likely to have sleep problems compared with individuals without arthritis³⁷ —an association independent of age. Being stoic about pain, it appears, does not diminish its consequences over time or help patients better tolerate it.

Stereotype #4: Prescription analgesics are highly addictive

Patients often think that prescription analgesics, especially opioids, are highly addictive or harmful—and older adults may refuse to take them for fear of becoming addicted.⁷ The stereotype is often shared by family and friends, as well as clinicians.

In one study, one-third of physicians said they hesitated to prescribe opioid medications to older adults because of the risk of addiction (a concern that no clinician with training in geriatrics shared).³⁸ What’s more, 16% of the physicians estimated that about one in 4 older patients receiving chronic opioid therapy becomes addicted. The actual risk is far lower. (More on that below.) News reports of an epidemic of prescription opioid addictions and fatalities,³⁹ including the assertion that opioids are replacing heroin as the primary drug of choice on the street,⁴⁰ may reinforce such stereotypes.

How great is the risk of addiction? For older adults, it’s very low

While rates of aberrant opioid use vary widely depending on the context, one consistent theme is that older age is associated with decreased risk.⁴¹ In one retrospective cohort study of older patients who had recently been started on an opioid medication for the treatment of chronic pain, only 3% showed evidence of behaviors associated with abuse or misuse.⁴²

What’s more, long-term opioid use among older patients with painful conditions is relatively uncommon, and prescription patterns suggest that most older adults discontinue opioids after one or 2 prescriptions.^42-44 Decades of research have found that, although opioid medications can cause physiological dependence, addiction is rare in patients treated with them.^45,46 (To learn more, see “Diagnosing and treating opioid dependence,” J Fam Pract. 2012;61:588-597.)

Debunking myths: Implications for practice

Our findings—that pain is not a natural part of aging and often improves or remains stable over time, stoicism does not lead to acclimation, and pain medications are not highly addictive in older adults—make it clear that the stereotypes we identified are misconceptions of pain in later life. Debunking these stereotypes has several implications for clinical practice. We recommend the following:

Identify and counter these stereotypes. Avoid reinforcing stereotypes; counter them by summarizing these evidence-based findings for older patients. We believe patients would be receptive.

In one study, more than 80% of patients with osteoarthritis said they wanted prognostic information about the course of the disease, but only about one-third had received it.⁴⁷ Presenting the research findings would challenge patients’ stereotypes and help them reframe their expectations.

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More than 80% of patients with osteoarthritis said they wanted prognostic information about the course of the disease, but only about one-third had received it.

Elicit patients’ perspectives. Ask patients about age- and pain-related stereotypes and their expectations and perspectives of what constitutes successful treatment. Research shows that patients often wish to discuss lifestyle changes and nonmedical approaches to pain, for example, but that clinicians typically focus on medications instead.⁴⁸

Emphasize the positive. Frame discussions of pain and aging in a positive light, offering encouragement rather than supporting stoicism or resignation. Attention to protective factors, including good mental health, self-efficacy, social support, and greater activity, may enable older patients to adapt better to any pain they experience.