Psychology and Chronic Pain in the elderly: A brief discussion (level 1)

University Degree Subjects allied to Medicine

Psychology and Chronic Pain in the elderly: A brief discussion.

Chronic pain is a complex condition which psychologists and other health professionals continue to attempt to understand. This essay will attempt to address: how chronic pain is defined; both the Gate control theory of pain (Melzack and Wall 1965a) and how it relates to the behaviourist models understanding of chronic pain; a short discussion on how chronic pain affects the elderly population and Cognitive behaviour therapy as an alternative to pharmacological and surgical treatment of chronic pain in this age group. To illustrate the discussion of Gate control theory Melzack and Wall 1965b) and the behaviourist model theory, this essay will include a brief reflection on two patients A and B who both presented with different kinds of chronic pain, and whom I cared for while I was working on a student nurse placement. This placement was undertaken in an acute medicine for the elderly ward.

Melzack and Wall (1965c) assert that chronic pain is independent of acute pain in diagnosis. According to Morrison and Bennett (2006) chronic pain lasts for more than three to six months and usually begins as acute pain caused by injury. Chronic pain may or may not have an identifiable cause. Chronic pain may be: intractable where pain is consistently present though intensity varies; periodic or progressive where pain increases with the progression of illness (Melzack and Wall 1965b).Chronic pain can be a symptom of injury or disease. However, Bonica (1953; cited in Melzack and Wall 1965d) points out that in some cases pain seems to remain past serving any known function. As with acute pain, chronic pain is increasingly recognised to be produced by the interaction of physical and psychological elements.

Melzack and Wall (1965e) propose the Gate Control Theory to address both the physical and psychological factors in explaining pain. The theory states that information is transmitted from sensory receptors, known as nociceptors, in the skin, tissue and organs to ‘gates’ in the spine. These gates open to transmit information to the brain. Simultaneously, connected emotions are felt such as fear and anxiety, which activate nerve fibres to transmit information from the brain. Physical and psychological information open the gate where pain signals enter the spinal column Melzack (1965 cited in Morrison and Bennett 2006b). Cognitive factors such as focusing on pain or the anticipation of pain can also open the gate and increase pain. Depression has also been noted to lower the pain threshold (Mel’nikova 1993; cited in Munafo and Turin). Conversely, relaxation and distraction can close the gate: decreasing the feeling of pain by inhibiting nerve impulses from travelling to the brain (Russell 2005a). Gate Control Theory accepts that psychological factors play an important role in the experience of pain.

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The Gate Control Theory addresses acute pain and chronic pain with physical and psychological elements. However, Loeser and Melzack (1999) argue that pain can originate without nociceptor input. Psychological factors such as positive reinforcement maintain pain once physical causes have healed, while emotional suffering may cause pain. Fordyce (1978a) proposes the behaviourist model of pain. He suggests that learned pain behaviours, which the brain associates with pain, are maintained by environmental cues and positive reinforcement. Pain behaviours include grimace, limp or groaning which can elicit sympathy, touch, help with chores or activities, and conversation which positively reinforce behaviours. Fordyce (1978b) suggests that environmental cues such as bed rest, medication or a clinical environment trigger pain behaviours as they are associated with an expectation of pain which can be self fulfilling (Brena and Chapman 1983). However, Engel, (1959 cited in Gamsa 1993) proposes that emotional pain can be felt as physical pain and realise emotional needs, caused by grief or loss. Physical pain may be more bearable than emotional distress. The suggestion that some chronic pain is psychological may mean that pain is treated as unreal, (Munafo and Turin 2000) and lead to pain being ignored or poorly managed.

There is a high incidence of chronic pain reported in the over 65 age group. Elderly patients accounted for 80% of complaints of chronic pain in a community survey carried out by Blyth, March et al. (2003 cited in Morris and Bennett 2006) Chronic pain affects every dimension of a person’s life, as it has a negative impact on economic, domestic, social, physical and psychological functions. Morris and Bennett (2006) The experience of chronic pain can lead to social isolation, poor quality of life and decreased ability to independently carry out activities of daily living. Ferrell et al (1990 cited in Gagliese and Melzack 1997a)

A high proportion of older people suffer pain which interferes with normal functioning, yet this is often inadequately managed by pharmacological and surgical treatment. Roy and Thomas (1987) and Woo et al (1994 cited in Gagliese and Melzack 1997b)

Medication and surgery remain dominant in the treatment of chronic pain in the elderly despite the complex variety of influences on pain. Gamsa (1993) suggests that this may be due to underestimation of the effectiveness of psychological treatment and misconceptions regarding older people’s compliance with these treatments. One psychological treatment of chronic illness which could help elderly patients to deal with chronic pain is Cognitive behavioural therapy.

Cognitive-behavioural therapy approaches pain management by helping the patient to control pain by teaching a variety of coping skills such as relaxation, distraction and positive imagery. These skills are based upon the cognitive, emotional, behavioural and physical which contribute to the perception of pain (Russell 2005b) CBT attempts to teach patients to understand the behavioural and cognitive elements of their pain. CBT is used to modify negative thoughts, reduce the experience of pain, and adapt coping skills into daily life. (Keefe 1996)

According to Harkins (1998 cited in Gagliese and Melzack 1997) elderly patients are under represented in chronic pain sufferers referred to clinics which offer these therapies. Gagliese and Melzack (1997) indicate that there is little evidence to suggest that elderly patients without dementia cannot be helped by CBT, on the contrary studies show that they may benefit as much as younger patients, suggesting that the decision to treat chronic pain in the elderly primarily with medicine and surgery is not evidence based practice.

While working as a student nurse on an acute medicine for the elderly ward I observed two patients who both presented with different kinds of chronic pain.

Patient A is a 72 year old woman discharged 16 weeks previously after treatment for stomach pain caused by constipation. A reported periodic stomach pain since discharge, however X-ray showed no faecal blockage, while various diagnostic tests proved negative. A’s pain appeared to have no current, identifiable, physical cause. A’s pain behaviours followed a pattern, consistent with the Fordyce (1978a) behaviourist model theory. A complained of pain mostly in mid afternoon when patients took an hours bed rest after medicine rounds. I noticed A frequently groaning and restless at this time and she confirmed that she was in pain. Both bed rest and medication rounds are identified as environmental cues by Fordyce (1978b). Mid afternoon is quiet and staff have time to attend to individual patients, so I sat with A when she reported discomfort, talked and rubbed her back which she said eased her pain. A showed pain behaviours at visiting hours which could imply that pain elicited positive reinforcement in the form of contact, sympathy and attention from staff and visitors. Conversely A rarely reported pain to medical staff reasoning that this would delay discharge and she reported being anxious to return home. Nursing staff suggested that A was attention seeking, however her behaviour does not seem consistent with this view. A’s pain in my opinion, was real, though caused by psychological factors, therefore treatment such as cognitive behavioural therapy could benefit A to cope with pain.

Patient B was a woman of 82 with terminal cancer and mild dementia suffering from progressive chronic pain. B’s pain had an, identifiable physical cause managed by analgesia. B sometimes became confused and anxious, requesting to leave. At these times pain appeared worse and she usually retired to bed. When rested, B was calm, engaging in conversation and at these times she did not report pain or display pain behaviours. When a patient died in a bed close to B, she became very upset, crying and pleading to go home. I approached B that evening as she was still distressed and she complained of ‘unbearable’ back pain. It was uncharacteristic of B to report pain or ask for additional medication; therefore I would suggest that the emotions she experienced increased her pain. This increase is consistent with the aforementioned Gate control theory proposed by Melzack and Wall (1965)

B’s dementia made her a poor candidate for a Cognitive behaviour therapy programme. However coping skills, such as relaxation and distraction, could be used with help from carers to control the psychological element of B’s pain. Relaxation is particularly relevant in B’s case as her pain appears less severe after resting.

To conclude, chronic pain is complex, and involves the interaction of physical and psychological factors. The Gate control theory has introduced a way of including both these factors, and the behaviourist model suggests a significant input by psychological elements. Elderly patients make up a large proportion of sufferers of chronic pain, with a great impact on the quality of life experienced in this age group yet their pain is often inadequately managed using medication and surgery. Evidence suggests that the elderly can benefit from psychological treatment such as cognitive behavioural therapy; therefore I would suggest that in the future more research and attention should be focused on implementing this.

Reference list

Brena, SF. and Chapman SL. (1983) Management of Patients with chronic pain. New York: SP Medical &. Scientific Books.

Fordyce, W.E. (1978) Behavioural Methods for chronic Pain and Illness. St. Louis: C.V. Mosby.

Loeser JD, Melzack R. (1999) Pain: an overview. Lancet; 3:1607-1609. (4.)

Melzack, R. and Wall, P. (1996). The Challenge of Pain. London: Penguin.

Morrison, V., and Bennet, P. (2006). An Introduction to Psychology. London: Pearson Education Limited. Munafo, M, and Trim J. (2000)

Chronic Pain: A handbook for nurses London: Butterworth-Heinemann Russell, J. (2005). Introduction to Psychology for Health Carers. Cheltenham: Nelson Thornes.

Gagliese, L., and Melzack, R. (1997) Chronic Pain in elderly people. Pain. 70 (1): 3-14

Gamsa, A. (1993). The role of Psychological factors in chronic pain. I. A half century study. Pain, 57, 5-15

Keefe, F. J. (1996). Cognitive behavioral therapy for managing pain. The Clinical Psychologist, 49(3), 4-5.