This is the second of a two-part series. In the first installment, an overview of pain in older people and pharmacologic pain management strategies were presented. This installment includes an analysis of complementary and alternative medicine (CAM) used for managing geriatric pain and a highlight of integrations of pharmacologic and CAM methods.
This offering expires in 2 years:September 29, 2010
The goal of this continuing education offering is to provide nurses with current information on managing the pain of older adults. After reading this article, you will be able to:
1. Describe strategies that complement pharmacotherapy for managing persistent pain of older adults.
2. Critique frequently used complementary and alternative medicine modalities for managing geriatric osteoarthritic pain.
3. Identify integrative approaches to managing older adults' persistent pain.
You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
If properly prescribed and delivered by professionals, complementary and alternative medicine (CAM) modalities "are rapidly becoming an expected standard of care for patients with chronic pain."1Because aging confers increasing risk of adverse drug reactions, including overdose and death, current approaches for treating pain combine both pharmacologic and nonpharmacologic methods, including CAM.1-3CAM approaches are not without risk, however, and interactions of pharmacologic and CAM modalities - resulting in drug-drug or drug-nutrient interactions - can be fatal.
Most consumers of CAM modalities who combine prescribed with self-prescribed over-the-counter modalities are satisfied with CAM - 80 percent in one large study of 1,200 community-living older adults - but underreport using CAM to their healthcare providers, typically because the latter do not ask about CAM use.4,5In another study that involved 557 participants, 63 percent of outpatients with osteoarthritis used both conventional and CAM practices, particularly those who experienced more pain and more difficulty sleeping.5However, efficacy research is not keeping pace with older adults' use of CAM modalities for managing chronic pain.
Nurses need to include patients' use of these preparations in medication inventories, and patient and family education goals need to include:
- maximizing efficacy of conventional and CAM modalities;
- minimizing interactions among them; and
- promoting patients' self-efficacy in managing their chronic pain.
Regardless of modalities used, the goals of pain management are the same:
- reducing pain;
- restoring or improving physical functioning;
- managing related emotional reactions (e.g., stress, anxiety, depression); and
- maintaining quality of life.
CAM Modalities: Pros & Cons
"Older adults are at risk of health complications related to their concomitant use of conventional and CAM therapies, especially with oral supplements."4 he use of CAM for managing persistent pain is increasing.4Generally speaking - related to a dearth of clinical trials, small sample sizes and methodological problems - evidence is not strong for the efficacy of most CAM modalities, but consumers continue to believe their use is without hazard.6
Table 1 lists diverse strategies used by older adults in managing pain. In a study of 1,200 community-living older adults, 62.9 percent used at least one CAM modality, typically for managing arthritic (44.4 percent) or chronic pain (25.5 percent) associated with other conditions. Modalities used with the greatest frequency were nutritional supplements, prayer or spirituality, herbs, large doses of vitamins and chiropractic medicine.4
In another study of 557 patients with osteoarthritis, spirituality/mind-body practices (43 percent), rubs (39 percent) and vitamins (31 percent) were used most frequently, with only 14.9 percent using physical activity to manage pain.5However, guidelines published by the American Geriatrics Society identify physical activity, cognitive-behavioral therapies and strategies for self-care management as having - among CAM strategies - the strongest evidence for reducing persistent pain. Additional patient education is needed to encourage use of evidence-driven modalities such as cognitive-behavioral strategies and physical activity that reduce pain without interacting with prescribed medications.
Preliminary in vitro research suggests certain plant derivatives have potential to reduce pain and function associated with arthritis by reducing inflammation and protecting cartilage from destruction.7 owever, additional in vivo research is needed. Table 2 highlights recent research on using CAM strategies for reducing persistent pain of older adults.
Studies typically have been observational, self-report surveys of patients' satisfaction with CAM strategies and typically lack:
- multivariate designs;
- large samples with equivalent control groups;
- psychometrically validated measures;
- implementation assessment and monitoring of protocols of standardized (and eventually regulated) products; and
- multisite replication to generalize effectiveness.
Well-powered clinical trials are needed to establish the efficacy and effectiveness of CAM strategies in preventing and treatingarthritis in older adults, particularly since their use is increasing.
The most common risk of using CAM - especially herbs and vitamin megadoses - with prescribed treatments is adverse interactions.4 Table 3 lists adverse reactions that can occur when medications that older adults may be taking for comorbid conditions are combined with CAM. Many drug interaction checker programs include over-the-counter herbs and supplements to assess their safety with prescription medications.
"Greater reductions in pain and improvements in function are usually obtained by combining pharmacologic and nonpharmacologic treatments."6Patients in persistent pain who use CAM strategies experience active involvement in their care and a sense of self-efficacy. This approach contributes to a sense of hope that their pain will be relieved. Therefore, nurses' role is not to discourage self-directed CAM use, but to educate the public about the pros and cons of using alternative strategies, particularly about potential interactions with prescribed treatments.
Because we respond as complex, unified mind-body beings to pain, older adults' self-care pain management needs to integrate the best practices of diverse modalities, particularly those the patient has found effective previously. Nurses' role is to critically evaluate older patients' regimens within the context of their pharmacokinetics and pharmacodynamics, ethnocultural practices, possible polypharmacy, social and financial resources, and adherence habits.
Cognitive-behavioral strategies that use a "structured, systematic approach to teaching coping skills" along with pharmacotherapy have had demonstrable efficacy.6Individuals with cognitive impairment may not be able to participate in cognitive-behavioral programs and should be offered other integrative approaches.
Persistent pain results in deconditioning when patients guard themselves from pain-exacerbating movement and decline from performing routine activities. Deconditioning, however, increases the intensity of pain, depression and anxiety. Table 4 outlines principles of promoting physical activity as part of a geriatric pain management regimen.
Participating in regular, safe and balanced physical activity - especially in socially interactive settings - is most consistently credited for:
- reducing osteoarthritic pain;
- increasing energy;
- increasing gait, balance and physical functioning;
- reducing disability;
- improving patients' self-care self-efficacy;
- reducing stress, anxiety and depression; and
- improving quality of life.6,8
Because persistent pain is strongly associated with depression and anxiety, treating geriatric pain with antidepressants and antianxiety agents may improve outcomes.2,3,9
In the context of risks involved with invasive interventions for managing geriatric pain, including iatrogenic complications and exacerbations of existing acute and chronic comorbidities, surgical interventions may need to be judiciously recommended if integrative, noninvasive modalities prove unsuccessful.
Collaborative decision-making about choice of therapies requires consideration of costs and benefits from a holistic perspective. McCarberg presents easy-to-follow algorithms - from least to most invasive - for managing osteoarthritic pain of older adults.10
References for this article can be accessed at www.advanceweb.com/nurses. Click on Education, then References.
Barbara Swanson is associate professor at the Rush University College of Nursing, Chicago.