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When Suzanne Leveille, PhD, RN, an epidemiologist at Beth Israel Deaconess Medical Center, Boston, and a faculty member at the University of Massachusetts Boston, had the opportunity to utilize data from the MOBILIZE (Maintenance of Balance, Independent Living, Intellect and Zest in the Elderly) Boston cohort study, she examined the relationship between chronic pain and fall risk in adults older than 70.
"During the 18-month study period, the 749 participants reported a total of 1,029 falls, with more than half the participants falling at least once during this period," she reported. "Participants with chronic pain in two or more joints had a 50 percent greater risk of falling than their peers who reported no joint pain." (Leveille, 2009)
Multiple Aching Joints
While two-thirds of community-dwelling seniors report chronic pain in one or more joints, this pain has never been evaluated carefully as a possible fall-risk factor, Leveille said. 
"We learned in our study it's the multisite chronic pain that seems to be the precipitating factor," she emphasized. "Fall risk did not go up with chronic pain in only one joint, but multisite chronic pain in the joints of the arms or legs was definitely a risk factor. It's the older adults with more complex, severe, disabling pain who are at higher risk for falls."
No one really understands the pathophysiology behind the risk factor.
"It could be chronic pain has an effect on the brain that makes it less capable of dealing with fall hazards, or perhaps it's a local effect in which the muscles in the area of chronic pain don't do as good a job of preventing falls," Leveille said. "Analgesic use in this older population is very low. They may be reluctant to take one more pill, especially because they may tend to understate or dismiss their chronic pain."
No Cross to Bear
The link between chronic pain and fall risk resonated with Judith Chessin, MSN, APRN-BC, geriatric psychiatric advanced practice nurse at Bridgeport Hospital, a Yale-New Haven Health facility in Bridgeport, CT.
"I wasn't at all surprised because I work with geriatric patients all the time, and am well aware of the chronic pain they experience," she said. "Some people believe pain is their cross to bear, while others may not be able to express their pain. When a patient with dementia is yelling, I often prescribe pain medication to see whether that makes the behavior better."
Chessin discussed some of the factors behind that link.
"There's so much osteoporosis, osteoarthritis and degeneration of the shoulders and hips in older adults," she said. "These patients may restrict their activities because of chronic pain. If you're not up and walking, muscles atrophy, strength is lost, and your sense of balance can deteriorate.
"If you have unrelenting pain, you can get discouraged, depressed and even suicidal," Chessin added. "These changes, especially in individuals who are in their 80s, can lead to falls and subsequent injuries."
Pain Management
Chessin emphasized the need for proactive pain management strategies.
"When an aide is pulling on an older woman to help get her out of bed, that patient can't tell the aide she's in pain," she said. "Instead, she may strike out at the aide to stop the pulling. When I'm working with older adults, especially individuals with dementia, I do a careful assessment of their musculoskeletal system to see whether there are limitations in range of motion or signs of pain."
Noting there are far too many myths about using strong analgesics for older adults, Chessin explained, "Narcotics are not contraindicated in the elderly, but we need to prescribe them thoughtfully. I like to use oxycodone, which is the narcotic component of Percocet, leaving the acetaminophen to be taken between doses if it's needed."
Oxycodone has a short half life and doesn't get metabolized into another drug in the body.
"It can be prescribed in a liquid form or tablet that allows us to easily titrate doses," Chessin said. "I might start with 2 or 2.5 milligrams of the drug and watch for side effects. If there are no side effects, and the patient still has pain, I increase the dose. It is important to address side effects that can occur with narcotic administration at the time of initiation, especially constipation. Senna-S 1 tablet daily may be enough, but this assessment should be ongoing with increases as indicated."
What about Inpatients?
Peggy Plunkett, MSN, APRN, PMHCNS-BC, psychiatric liaison clinical nurse specialist at Dartmouth-Hitchcock Medical Center, Lebanon, NH, would like to see the study replicated in the inpatient setting.
"I would need to see how much the assessment of chronic pain added to our evaluation of fall risk of patients on admission and thereafter," she said. "All hospital patients are at risk for falls and our fall-risk assessments are focused on those at the highest level of risk."
Plunkett wondered about the cost/benefit ratio of adding chronic pain to fall-risk assessments.
"I don't know if we asked every single elderly patient on admission whether they had these chronic pain problems, we would see a higher incidence than in the community-based population," she explained. "If that's the case, adding chronic pain to our assessments might lead to identifying virtually all elderly patients as high fall risks."
And, Plunkett, noted, "Another piece to consider is how much of a difference fall-risk assessments make to begin with. Are fall-risk assessment tools significantly more effective in the hospitalized elderly than nursing clinical assessments in general? Our focus here is more on what kinds of interventions we're putting into place to reduce falls by modifying the environment."
Implications for Practitioners
This landmark study, with a nurse as lead researcher, has plenty of implications for health care workers.
"The study really points to the need for more complex pain assessment in older adults," Leveille said. "When we evaluated their pain in the study, we asked about chronic pain in several joint areas - feet, knees, hips, back, shoulders and wrists. We learned multisite joint pain was much more common than chronic pain in only one joint area.
"This is one of the first studies to link pain to a serious hazard in older adults," she noted. "Chronic pain is not just a bothersome ache - it puts seniors at risk for falls and serious consequences of falls such as fractures and hospitalizations."
Resource
Leveille, S. G. et al. (2009, Nov. 25). Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA, 302(20), 2214-2221.
Sandy Keefe is a frequent contributor to ADVANCE.
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