A national survey recently found that 48 percent of those age 75 or older had chronic joint symptoms whereas the occurrence of these symptoms among those who are 18 to 44 years of age was 16 percent.¹ These statistics are consistent with an increase in the prevalence of arthritis with age. In 2002, approximately 48 percent of people age 65 and over reported having been diagnosed with arthritis. The percentage increased to 51 percent for those 75 and older.²

Even though individuals may expect to have more pain as they get older, their belief that “you just have to live with it” often interferes with how they manage pain. Taking a proactive approach requires a change in how one views “living with pain.”

It is important to view pain management as more than pain relief or a reduction of pain intensity. Effective management also involves adjusting to or softening the effects of pain under a variety of circumstances, along with having the confidence that one can do what is required to modulate the pain.³

Teaching or guidance by a health care practitioner is important to individuals as they practice using new modulation techniques. Examples of techniques often found useful include mind-body strategies such as diversion, relaxation, imagery and positive self-talk. Physical strategies, such as exercise and the use of heat and cold, can also be beneficial. Weight control and pacing activities to avoid fatigue may be helpful as supportive approaches. People select activities that fit them best. As they gain confidence in using these methods, they will be more likely to perform them almost automatically when needed to modulate their pain.
Pain management misconceptions often exist. It is important that practitioners recognize and address these so poor communication about pain and, subsequently, poor pain management do not occur.

Understanding The Roles Of Pain Tolerance And Pain Threshold
Whether pain perception decreases with age is debatable. While there have been studies on the perception of acute pain, there have been mixed results concerning the relationships among pain tolerance, pain threshold and age.⁴

While pain tolerance may be described as intensity or the duration of pain one is able or willing to tolerate, pain threshold is defined as the least amount of pain that one can recognize.⁵ Both tolerance and threshold might be expected to differ from time to time, depending on the experiences of the individual. Available studies have used stimulus-induced pain. Whether this approach provides information that is clinically relevant to chronic pain is questionable since it does not really reflect the broader pain experience.
We should not assume that sensitivity to pain decreases with age.⁶ In addition to lacking objective support, this belief may be irrelevant to pain management. Since one cannot separate the sensory dimension of pain from the affective and cognitive components, it is important that we comprehensively evaluate and treat each individual's pain. The fact that older people experience more comorbid conditions may actually increase the degree of suffering or the affective and cognitive pain components.

Are Older Patients Willing To Learn New Techniques?
Another mistaken belief of practitioners that needs correction is that older adults are unwilling to learn new pain management techniques. Older adults use nonpharmacological methods (e.g., relaxation, positive self-talk and exercise) significantly less often than younger individuals.⁷ However, this is most likely because they are not being introduced to and taught these approaches as opposed to a lack of willingness to use them.⁸

Older adults are underrepresented in multidisciplinary pain programs that focus on providing education that addresses the multidimensional nature of pain that may include disturbances of mood, sleep and function.
Older adults are more likely to experience adverse effects from medications, especially when they have comorbidities requiring various treatments. This serves as a motivator for using alternative pain management strategies. Diversion, for example, is a technique that many have learned to use, almost instinctively, as a management method. Individuals find that becoming involved in activities takes their minds off their pain. Other methods that may be helpful, and require minimum teaching and practice, include muscle relaxation, imagery and positive self-talk.

The positive relationship between exercise and pain management for those with arthritis has been well documented, showing possible improvements in pain threshold, joint flexibility, fatigue level and functional ability.^9,10 There are many types of exercise that can be adapted to each person’s capabilities, resources, interests and goals. In order to improve adherence to those selected activities, practitioners must work with their patients to set realistic goals, ensure an adequate comfort level with performance, identify possible barriers that might occur and how to address these obstacles, and monitor progress. As the patient makes progress, one may reevaluate goals to increase the amount of exercise or add additional exercises.

Addressing Patient Assumptions About Managing Their Pain
Older adults believe that being stoic about their pain is better than addressing it. They are often reticent to mention their pain to others including health care providers.¹¹ To some, not mentioning their pain is part of being a “good” patient. Knowing this, practitioners should take the lead in assessing the individual’s pain and discussing how it is being managed. When older adults do mention or acknowledge their pain, they may be asking for help in finding ways of managing it that will complement the use of medicine and perhaps facilitate using less.¹²

For most people, using medicine for pain relief will remain an important part of comprehensive pain management. Therefore, helping patients find a medicine, and the correct dose, that provides some relief without causing adverse side effects becomes a challenge for practitioners.
Waiting to take medicine for pain until the pain is at its worst is a misconception that interferes with achieving the best relief. Teaching a patient the importance of taking medicine when pain first begins or on a scheduled basis to control pain is important.

A useful strategy is having patients be their own self-monitors. Have them use a form to record when they take medicine and what the perceived pain intensity is over time. Not only will this increase the patient’s knowledge of how the medicine (and its timing) is working, it will also help the practitioner to determine the medicine’s effectiveness within the parameters of its use.

In Summary
Chronic pain associated with arthritis is multidimensional in nature. Accordingly, it requires the use of a variety of self-management approaches that address both relief and modulation. Having an assortment of strategies at hand is necessary for achieving positive outcomes related to reducing pain intensity and increasing mood, function and sleep quality. Achieving pain management success involves self-management by the patient and support from practitioners through ongoing assessment, appropriate teaching and careful monitoring.