How can pain be managed for a 90 year old woman?

A fellow caregiver asked...

How can pain be managed for a 90 year old woman? It seems that it is either arthritis or the additional lower spine scoliosis type shape that causes excruciating pain in the mornings in the back, upper thigh area. It is impossible to get out of bed and attend to any morning routines with this pain. She is on Gabapentin 600mg/night and Tylenol #3/3x's/day but these are not providing any relief. It is so unfair to live this long and then spend the last of your time in such pain. We are concerned that any narcotic may make her dizzy and also cause constipation. We have changed primary and also seen a rheumatologist. The pain persists. If there was something to make it just manageable, this would be wonderful. The doctors have also suggested physical therapy, but she is not mobile enough to go. Is there anything that would help?

Expert Answer

Jennifer Serafin, N.P. is a registered nurse and geriatric nurse practitioner at the Jewish Homes for the Aged in San Francisco.

In my experience, pain can be managed for anyone at any age, if the right modalities are used. I read your letter several times, and I understand that you are concerned about narcotic usage because you are worried about constipation and dizziness in a 90 year old woman.
I want you to understand that most of the patients I care for have chronic pain conditions and are at least in their late 80's to 90's. The key to managing chronic pain in older persons is to use several different modalities in combination. This includes medications along with heat or cold applications, analgesic balms, exercises/PT, massage, and other non-drug options. The most important thing to keep in mind is that she needs to have her pain treated enough so that she can have a good quality of life.

Having a severely curved back can be painful, but this can be caused not only by arthritis, but osteoporosis as well. Osteoporosis can cause fractures in the bones of the spine itself. This leads to a profound curvature of the spine, which can make someone's posture look as if they are hunched over, and they cannot stand up straight. Or, she may have scolosis itself, which is where the back is curved in a "S" shape. There are many other painful spinal conditions that she may have that are causing her pain tooas well. Has she ever had an Xray or MRI? These tests would allow you to get a more solid diagnosis for what can be causing her pain.

You mention that she is on Tylenol #3, which has codiene in it (which is an opiate/narcotic that is VERY constipating) and Gabapentin, which is a nerve medication that can cause dizziness and fatigue. Unfortunately, these are not working for her, so she needs stronger medicatons. In my experience, codeine is usually not a great pain reliever. I would recommend having her try something like Oxycodone (5mg three times a day) with tylenol (2 tabs of the 500mg four times a day- the maximum dose) for the pain. If this is not enough, the Oxycodone dose can always be increased until her pain is better controlled. Another medication that she could try instead of Gabapentin would be Ultram (good for nerve pain), but I would not use this medication alone without an opiod, as it does not always work well by itself.

Regarding side effects of opiods/narcotics, stronger opiods do cause constipation, but this can be managed with laxatives. She should start on a good laxative (not Colace- it is a stool softener only) as soon as the opiod medication is changed, so that this side effect can be avoided. I like Senekot for a laxative, as it works well with opiod induced constipation. She can start on one tab a day, as go up as her health care provider recommends. As for dizziness, this in not really a common side effect I encounter.

As for non-drug therapies, she can also try a analgesic balm on her back like Ben Gay, Salonpas, or Aspercreme. I would massage a cream of her choice on her back in the mornings, as this is her bad time. You can try cold washcloths (put in the freezer and get them really cold but not yet frozen) or a heating pad too. Use whichever one she likes. You can apply them up to 3 times a day for 20 minutes- just make sure her skin is protected from burning. Keep in mind that some people like to take warm baths in the morning, as this can help reduce pain.

If her pain improves, I think that she would be more likely to get PT or exercise therapy. Please speak to her new doctor about trying some of my suggestions, as I think they will help. Good luck!