Older patients in an emergency room are less likely to receive adequate pain treatment than younger people are, even when pain levels are the same, according to a seven-year study published online in the Annals of Emergency Medicine.

"We were interested in learning why older adults often receive less pain medication in the ER," says Timothy Platts-Mills, MD, lead author of the study and an assistant professor at the University of North Carolina School of Medicine in Chapel Hill. "Other studies had reported on treatment disparities, and we wanted to find out more."

So Dr. Platts-Mills and his colleagues examined hospital survey data on more than 88,000 pain-related emergency room visits across the United States from 2003 to 2009 – a representative sampling of 43 million actual pain-related visits during that period.

After taking into account gender, race, pain severity and other factors, they found that just 49 percent of adults older than age 75 were given pain medication compared with 65 percent of people aged 35 to 54. Even when reporting severe pain, older adults were 12 percent less likely to receive pain-relieving drugs than middle-aged patients with similar symptoms.

"The data doesn’t tell us why this is happening," Dr. Platts-Mills says, "but there are probably multiple causes."

Generational differences

One factor, he believes, is generational. "This is the generation that grew up in the Depression and fought in World War II. They're less likely to make requests of physicians, less likely to complain and less likely to accept pain medication. Our study didn't show whether some patients who were offered analgesics declined to take them."

Heather Whitson, MD, an assistant professor of medicine at the Duke University Aging Center in Durham, N.C., who was not involved in the study, agrees that generational differences may play a role.

"Older adults tend to understate their pain – out of stoicism and also out of deference to authority. They want to be good patients, and asking for pain relief requires an assertiveness they may not feel comfortable with."

She adds that age-related problems with memory, hearing and vision can be barriers to good communication between providers and patients, too.

Drug concerns

Worries about drug interactions and side effects may also contribute to undertreatment, Dr. Platts-Mills says.

"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."