3A Model Helps Clinicians Explore Older Adults' Attitudes Toward Nonpharmacologic Pain Management

Over one-third of older adults experience chronic pain. Two-thirds of older adults with chronic pain report pain at multiple sites and more than 60% describe multiple types of pain. Yet older adults are less likely than younger adults to use nonpharmacologic approaches to pain management, and little is known about why they choose specific options.

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Christine Seel Ritchie, MD, MSPH, director of research in the Division of Palliative Care and Geriatric Medicine and director of the Mongan Institute Center for Aging and Serious Illness at Massachusetts General Hospital, and colleagues report in Pain on their qualitative study of factors that influence the use of nonpharmacologic approaches by older adults who have multiple chronic pain conditions.

Study Methods

The team recruited 25 English-speaking older adults, age 65 or older (mean, 72; range, 66–90) who had at least three chronic medical conditions and had experienced persistent pain for at least six months. 64% were female.

On average, participants had six chronic conditions (range, 3–12), all reported regularly experiencing pain that interfered with daily activities and all were currently using at least one nonpharmacologic intervention (mean, 5.6).

A single researcher conducted a single semistructured interview with each participant, asking what factors influenced their decisions to consider, initiate, start, continue or stop using nonpharmacologic pain management approaches. The interviewer inquired about acupuncture, massage, chiropractic, physical therapy, mindfulness/breathing exercises, working with a psychotherapist, exercise, yoga, tai chi and ice. Participants reported a wide range of other interventions (e.g., walking, heat, resting, home-based exercise and use of orthopedics).

After formal, iterative analysis of interview transcripts, the team proposed the "3A model" of barriers and facilitators: those that influenced participants' awareness of an approach as an option relevant to them, those that influenced the appeal of the approach and those that influenced access to the approach.

Awareness

Individuals must not only be familiar with an intervention but also recognize it as germane to their condition. Multiple participants were unaware of some of the common approaches the interviewer raised, and in other cases they did not consider an approach relevant to managing chronic pain or their specific case.

For example, multiple participants believed movement such as yoga might help chronic pain but were familiar only with styles of yoga they felt they could not perform because of physical limitations.

Appeal

Numerous participants' narratives revealed they did not like or value certain approaches and therefore did not initiate them, continue using them or even consider them.

In some cases, these decisions were tied to individuals' perception of the approach as ineffective for their pain. In other cases, participants considered the approach uncomfortable, unpleasant or boring, unsatisfying, illegitimate or doubtful (e.g., some were skeptical about Eastern medicine) or misaligned with their self-concept (e.g., "I just cannot picture myself doing Zen stuff.").

Individuals who found an approach appealing did not necessarily feel exclusively positive about it; for example, sometimes an approach that helped one source of pain exacerbated another. Conversely, sometimes an approach's effectiveness did not outweigh the discomfort or dislike the participant felt about it.

Access

The main aspects of accessibility cited were the affordability of the approach, the participant's physical and/or cognitive capacity to use it and logistical factors.

Participants described physical constraints as interfering with their ability to engage in yoga and certain exercises or even trying these approaches. Cognitive limitations (e.g., memory and concentration) were mentioned less often but also created barriers. For example, some participants were unable to do PT exercises or meditate at home because they could not remember how.

For some participants, transportation to appointments was inconvenient, burdensome or impossible. Other logistical barriers included practical aspects of the approach itself (e.g., the format of PT), restrictions on the number of visits, the closure of a clinic or class, and the departure of a preferred practitioner.

A Conversational Roadmap

Assessing a patient's openness or resistance to a specific nonpharmacologic approach requires the clinician or researcher to discuss with patients how barriers and facilitators are operating for each of the 3A's. The authors suggest questions to use during these consultations:

• Awareness: "Did you know that ___ is something that may be able to help with your pain?"
• Appeal: "Would you be willing to try ___? Can you think of anything you may not like about doing ___? Does anything make you think ___ would not help with your pain?"
• Access: "Can you think of anything that would make it difficult for you to acquire ____? Use ____? Get to ____?"

These questions should be revisited periodically and whenever a new nonpharmacological approach is considered.

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