"Older patients tend to take more medications and are more sensitive to side effects, so there is concern about causing harm. But not treating people also causes harm, in terms of both immediate suffering and the long-term health consequences of untreated pain. You can almost always provide safe pain relief for older people with reduced doses or appropriately chosen medicines," he explains.

Dr. Platts-Mills stresses the need for more studies on the risks and benefits of short-term pain therapy as well as better medications and alternatives that would mitigate some drug side effects.

The same is true for long-term pain management, according to Dr. Whitson.

"For people with chronic diseases such as arthritis, we are always walking the line between side effects and pain. Pain is a moving target, and we constantly have to re-evaluate and change course."

Compounding the problem of drug interactions is the issue of inadequate follow-up care. "ER doctors would have more peace of mind if they knew there were a seamless transition to post-emergency care. But they can't be sure [that a patient will receive ongoing treatment], so they're leery about administering even one dose of a drug that might have an adverse effect on someone who is frail and vulnerable," says Dr. Whitson.

Ageism issues

Dr. Platts-Mills acknowledges that ageism also influences emergency room care.

"Our study suggests that providers are less attentive to pain in older patients, perhaps because they are less able to relate to and empathize with them. Physicians are more likely to provide optimal treatment to patients who are most like themselves, and it may be easier to sympathize with a young soccer player with a sprained ankle than an 80-year-old woman who injured her back in a fall," he says.

Dr. Whitson notes that ageism may play an even bigger role when patients have pain that can be attributed to a chronic, age-related condition. "When pain is chronic," she says, "it's more likely to be ignored."

Finding a solution

Nearly half of the 20 million annual emergency room visits by people older than 65 are for evaluation and treatment of pain. Failure to manage pain well causes unnecessary suffering and is associated with decreased quality of life, poor sleep, falls and increased mortality, Dr. Platts-Mills says.

He adds, "The biggest challenge for my generation is how to maximize the independence and physical functioning of older adults. This is something we owe them."