In this analysis of national trends in ED practice, more than half of all pain-related visits by patients 75 or older and a third of those with severe pain did not receive an analgesic. During the 7 years analyzed, visits by patients 75 or older were approximately 19% less likely to receive pain medication than were visits by patients 35–54. This estimate remained after adjustment for measurable confounders including pain severity. These estimates suggest that of 6 adults age 75 or older presenting to an ED with pain, 1 fewer would receive analgesic treatment than if all 6 patients were middle-aged. Pain-related visits for the oldest adults were also less likely to result in the administration of an opioid or an NSAID, and differences were present regardless of pain severity or whether the patient was being admitted or discharged. Differences in the frequency of analgesic administration between the oldest and younger patients persisted across the study period. Pain-related visits by adults age 18–34 and adults 55–74 were also significantly less likely to receive pain medication than patients age 35–54, but the difference was less pronounced in these age groups than for the oldest age group.
Our results are consistent with those from single-site studies which found lower rates of opioid administration for older adults for all pain-related visits15
and lower rates of discharge prescriptions for opioids for older adults.14
No prior study has reported lower rates of administration of analgesics in general for all types of pain-related ED visits for older adults. Thus, the present report extends the findings of prior studies and identifies oligoanalgesia in older ED patients in the US as a general phenomenon. Our findings add to the body of literature which is the basis for the recent Institute of Medicine
report which describes the enormous burden of pain in the US and calls for a “transformation in the way pain is understood, assessed, and treated.”29
A number of factors may contribute to reduced pain treatment in older adults. Emergency providers may choose not to given analgesics to older adults because of concerns about potential short term30,31
or long term19,32–35
adverse effects. However, the observed difference in pain medication administration rates among admitted patients suggests that concerns about side effects in older adults do not entirely explain differences in rates of analgesia administration because providers concerns about side effects such as falls and sedation should be reduced for admitted patients. Because severe illness or injury is more common in older adults, there may be increased attention placed on diagnostics and less attention on treating pain for these patients.9
In this context, patient self-advocacy may be an important determinant of receiving pain treatment, and older patients may be less effective advocates than younger patients for the treatment of their pain. Documentation of pain severity is more often missing for older adults, and patients with missing pain severity scores are less likely to receive analgesics,36
suggesting that providers are less attentive to pain in older ED patients. In some older adults, patient failure to request analgesics or provider failure to recognize pain may be due to cognitive impairment.37
These potential barriers to care may be further compounded by limited formal training of emergency providers in the care of older adults.38
The treatment of pain in older adults is important not only to achieve an immediate reduction in suffering but also because untreated pain may impact long term health outcomes. Patients who present to the ED with pain and don’t receive treatment are likely to leave the ED with pain.39
Persistent pain in older adults is associated with decreased quality of life,40
perhaps mediated through increased stress43
or pain’s effect on function.44
However, effective management of acute pain is associated with reduced persistent pain and improved function at 6 months in older patients following orthopedic surgery,45
suggesting that treating acute pain in ED patients has the potential to improve long term outcomes. Because of the negative effects of pain in older adults and the potential to reduce persistent pain by treating acute pain, the effective management of acute pain in this population is an important priority.
We found that pain-related visits by adults age 75 or older are less likely to result in analgesic treatment than visits by middle-aged adults, even after adjusting for pain severity. Our results suggest that additional efforts are needed to understand and overcome obstacles to the treatment of acute pain in older adults in the United States. In particular, additional research is needed to better define the relationship between analgesic administration for acute pain and long term health outcomes, determine the frequency of and risk factors for adverse effects from the short term use of analgesics, develop strategies to minimize adverse effects, and incorporate pharmacologic therapy into a multidisciplinary approach to pain management for this large, growing, and vulnerable population.