Hypnosis for = Pain Management in the Older Adult

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Hypnosis for Pain Management in the Older = Adult

Norma G. Cuellar, DSN, RN

Pain Manag Nurs. 2005;6(3):105-111. = =A92005 W.B.=20 Saunders

Posted 10/21/2005

Abstract and Introduction

Abstract

Pain is a physical, emotional and psychologic phenomenon that = is often=20 ignored in older adults causing depression and poor quality of = life. Older=20 adults report the use of complementary and alternative medicine in = some=20 form with 80% of these users reporting improvement in their health = conditions. Although physical pain in the older adult is usually = managed=20 with pharmacologic interventions, Methods that may reduce the use = of=20 prescription drugs may decrease adverse effects that can = compromise the=20 physiologic state of the older adult. Hypnosis has continued to = gain=20 acceptance within mainstream medicine as an appropriate treatment = and can=20 be integrated safely with conventional medicine as an effective = treatment=20 for a variety of conditions in the older adult. It is an = intervention that=20 can be used for relaxation and pain control, especially when = conventional=20 pharmacologic regimens have failed. The Purpose of this article is = to=20 review the concepts related to pain in older adults; the use of=20 complementary and alternative medicine in the older adult; = hypnosis and=20 the older adult (i.e., background, definition, benefits, research, = mechanism of action, hypnotizability, and the process); and the=20 implications of using hypnosis for pain management in the older = adult.

Introduction

Hypnosis is one of the oldest and most documented psychologic=20 interventions for the reduction of pain and suffering. In recent = years, it=20 has become an increasingly more acceptable therapeutic = intervention by=20 health care providers in a variety of settings. Although = scientists differ=20 on theories about the nature of hypnosis, it is obvious that = persons who=20 are hypnotized report changes in the way they feel, think, and = behave.=20 Research studies are inconclusive about the outcomes of hypnosis. = However,=20 many studies (Ashton et al., 1997; Cadranel et al., 1994; Chaves = &=20 Dworkin, 1997; Hrezo, 1998; Lang, Joyce, Spiegel, Hamilton, & = Lee,=20 1996; Marchioro et al., 2000; Patterson & Jensen, 2003; Van = der Does,=20 Van Dyck, & Spijker, 1988) have demonstrated that = self-hypnosis in=20 persons who experience pain or stress can reduce the need for pain = medications.

Outcomes of untreated or mistreated pain in the older adult can = lead to=20 depression, anxiety, and feelings of hopelessness. Hypnosis may be = an=20 option for the older adult who does not want to take pharmacologic = agents=20 for chronic pain. To date, only a limited number of studies have=20 documented the outcomes of hypnosis in the older adult (Ashton et = al.,=20 1997; Gay, Philippot, & Luminet, 2002; Lang et al., 1996). = However,=20 research needs to be done that uses gerontologic concepts and = Methods when=20 using hypnosis in older adults. This article provides an overview = of=20 concepts related to pain in older adults; the use of complementary = and=20 alternative medicine (CAM) in the older adult; hypnosis (i.e., = background,=20 definition, benefits, research, mechanism of action, = hypnotizability, and=20 the process); hypnosis and the older adult; and the implications = of using=20 hypnosis for pain management in the older adult.

Pain in Older Adults

Pain is a common occurrence in older adults. Severe and = persistent pain=20 can be debilitating and have consequences that compromise health = care=20 outcomes and survival (Alden & Heap, 1998;=20 http://www.asaging.org/at/at-195/pain1.hmtl. Elders in pain=97gaps = found in=20 research and practice, 1998). Up to 40% of community-dwelling = older adults=20 have pain with up to 83% of older adults in long-term care = facilities=20 reporting pain (Chodosh, Ferrell, Shekelle, & Wenger, 2001). = Because=20 of the increased prevalence of chronic illness in older adults, = pain is=20 seen twice as often in this group than in younger cohorts. There = is a=20 substantial cost associated with pain in the older adult related = to=20 depression, social isolation, sleep disturbance, gait problems, = and=20 increased use of health care services (Chodosh et al., 2001).

Reports of pain are the leading reason for office visits among = older=20 adults. In any health care facility, pain management is an = important=20 activity for those who work primarily with geriatric patients = (Dellasega,=20 2000). In seeking more effective, less expensive treatments for = pain,=20 older adults are in need of current information to make informed = decisions=20 about complementary and alternative therapies to decrease their = risks of=20 adverse reactions and complications that may result from = pharmacologic=20 interventions. Although most painful, chronic conditions are = treated with=20 pharmacologic interventions, these often pose some risk for the = older=20 adult. In reality, the older adult is often given improper or = inadequate=20 pain medication prescriptions (Kemper, 2002).

Common myths occur in relation to pain and older adults = (Dellasega,=20 2000; Potash, 2003; Victor, 2001) ( Table 1 ). Some of these myths lead to = inadequate pain=20 control because older adults receive ineffective doses of = analgesics or no=20 treatment for pain. Untreated pain can affect health outcomes in = older=20 adults. For example, immobility is used as a way to control pain, = which=20 may lead to numerous negative consequences including = deconditioning,=20 depression, and social isolation (Kemper, 2002).

Aging can affect the metabolism of medications (i.e., = absorption,=20 distribution, metabolism, and excretion) and alter the = effectiveness of=20 pharmacologic interventions for pain management (Ebersole & = Hess,=20 1998). Absorption may be affected because of changes in = gastrointestinal=20 motility=97the absorption may be either increased or decreased.=20 Distribution, metabolism, and excretion of medications should be=20 considered depending on the condition of essential organs, like = the liver=20 and kidneys, when prescribing any medication for the older=20 adult.

The Use of Complementary and Alternative Medicine in Older = Adults

One option for pain management in older adults who do not want = to use=20 opioids or other pharmacologic agents is the use of CAM. According = to=20 recent studies (Cherniack, Senzel, & Pan, 2001; Eisenberg et = al.,=20 1998), 42.1% of the American population uses some form of CAM, = with 39% of=20 the older population using CAM. A more recent study (Williamson et = al.,=20 2001) identified an even higher percentage (73%) of older adults = using=20 CAM, much higher than the national average. Of the older adults = who use=20 CAM, 58% reported that they did not discuss the use of CAM with = their=20 medical doctor or health care practitioner (Astin, 1998).

By the year 2020, older adults will make up 22% of the total = population=20 (Ebersole & Hess, 1998). Because of a predicted increase in = chronic=20 conditions, older adults may choose to use CAM more often to help = manage=20 their health. This aging group of baby boomers may be more = receptive to=20 the use complementary and alternative therapies, including = hypnosis.=20 Despite the growing number of older adults using CAM, little = information=20 is available to this segment of the population regarding treatment = options=20 of CAM, specific costs, benefits, risks, or precautions pertinent = to this=20 age group.

The older adult reports the use of CAM in the following chronic = conditions: arthritis, back pain, heart disease, allergies, and = diabetes=20 (Foster et al., 2000). For these conditions, the most common types = of CAM=20 are chiropractic medicine, herbal remedies, relaxation techniques, = megavitamins, and religious or spiritual healing (Foster et al., = 2000).=20 Complementary and alternative medicine therapies, like herbal = remedies=20 (e.g., ginkgo biloba and ginseng), vitamins, music therapy, touch, = massage=20 therapy, and neurofeedback, may improve cognitive function in the = older=20 adult (Adams, Gatchel, & Gentry, 2001).

Hypnosis is a treatment that can alleviate pain and may help a = patient=20 to feel empowered, have an increase in self-esteem, and develop = more=20 positive health attitudes without the side effects of opioids = (e.g.,=20 sedation, decreased mental status) (Lynch, 1999). Older adults = with intact=20 cognitive function may use hypnosis, taught in one-on-one = instruction or=20 in a group setting, to control pain and decrease the use of = pharmacologic=20 agents.

Hypnosis

Background on Hypnosis

Hypnosis is one of the oldest and most documented psychologic=20 interventions for reducing clinical pain and suffering (Doody, = Smith,=20 & Webb, 1991). Hypnosis for sedation was used widely before = the=20 development of safe and effective surgical anesthesia (Chaves = &=20 Dworkin, 1997). In the 19th century, it served as the sole = anesthetic for=20 minor and major surgeries in India. Physiologic benefits from = hypnosis=20 were observed, but not fully understood, including decreased heart = rate,=20 decreased respirations, improved mood, and overall relaxation. In = the past=20 decade, hypnosis has increasingly become an adjunctive therapy in = the=20 management of pain in the acute care setting as well as in = outpatient=20 settings (Chaves & Dworkin, 1997; Doody et al., 1991; = Montgomery et=20 al., 2000). It has been shown to be effective in reducing both = clinical=20 and experimental pain (Montgomery et al., 2000). Interest to = incorporate=20 hypnosis into clinical practice has increased because it seems to = be=20 cost-effective and because recent neuroimaging studies have = provided an=20 increased understanding of the mechanism of action of hypnosis = (Patterson=20 & Jensen, 2003).

Definition . . . What Is Hypnosis?

Hypnosis is a "mind=96body" connection that an individual goes = through=20 using an established ritual that can affect neurotransmitter = release and=20 relieve pain through concentration and relaxation (Anderson, = 2000). After=20 a repetitious verbalization, action, or movement, the individual = becomes=20 attached to a desired outcome. Quick entry into a natural and = spontaneous=20 trance occurs, in which pain relief takes place, like the state = you enter=20 before falling asleep=97pleasant and relaxing. Hypnosis is not = lack of=20 consciousness or mind control but a heightened sense of personal = internal=20 awareness and control (Hrezo, 1998). The patient is always in = control and=20 can "wake up" whenever she or he desires to do so. Physiologic = responses=20 to hypnosis (e.g., changes in the sympathetic responses, = endogenous opioid=20 responses, and possible inhibition of neuronal firing at the = spinal cord=20 level) have been documented through evoked potential studies,=20 electroencephalogram studies, and brain imaging studies (Patterson = &=20 Jensen, 2003).

Benefits of Hypnosis

Hypnosis often reduces pain even when traditional medical and=20 psychologic interventions have failed (Alden & Heap, 1998; = Chaves=20 & Dworkin, 1997; Hrezo, 1998; Patterson & Jensen, 2003). = Beyond=20 the obvious reductions in pain that can occur with hypnotic = suggestions,=20 there are additional benefits (Figure 1) (Nash, 2004; Williamson = et al.,=20 2001). Unlike other behavioral Methods of pain treatment, hypnosis = has the=20 potential to provide rapid pain relief that can be maintained for = long=20 periods of time (Gay et al., 2002). Although pharmacologic = treatment for=20 pain is still appropriate, when pain medication does not provide = adequate=20 pain relief, hypnotic techniques can be added easily to the = treatment=20 regimen (Hrezo, 1998; Thomas, 1991).

Figure 1.
Benefits of hypnosis.

Because hypnosis can be provided in a group format and can = potentiate=20 the efficacy of cognitive behavioral therapy, hypnotic techniques = can be=20 time efficient. When patient care is enhanced through the use of = hypnotic=20 techniques and medical complications are reduced, the cost = effectiveness=20 of hypnosis becomes obvious (Montgomery et al., 2000). Older = adults who=20 attend group sessions in long-term care facilities may benefit = from having=20 hypnosis integrated in these activities.

Is There Research That Supports the Use of Hypnosis in Pain=20 Management?

Comparative efficacy studies have demonstrated that hypnosis is = often=20 more effective than biofeedback, relaxation, cognitive behavioral = therapy,=20 acupuncture, or morphine for both acute and chronic pain with 75% = of those=20 who use hypnosis experiencing some relief of pain (Patterson & = Jensen,=20 2003). Hypnotic techniques have proven useful for pain associated = with=20 burns, cancer, invasive medical procedures, headaches, = musculoskeletal=20 conditions, irritable bowel syndrome, and fibromyalgia (Haanen et = al.,=20 1991; Lynch, 1999; Montgomery et al., 2000). Hypnosis has = demonstrated=20 particular utility for reducing cancer pain, including bone marrow = transplant pain and coping with invasive procedures associated = with cancer=20 treatment (Ernst, 2001; Handel, 2001; Lynch, 1999; Marchioro et = al., 2000;=20 Pattison, 1997; Renouf, 1998).

What Is the Mechanism of Action of Hypnosis?

Pain reduction with hypnosis is not due solely to nonspecific = effects=20 such as relaxation or anxiety reduction. In contrast with what = many=20 medical professionals believe, hypnotic pain reduction is also not = achieved through the placebo effect (Alden & Heap, 1998). = Furthermore,=20 it is generally accepted that hypnotic analgesia is not mediated = by the=20 endogenous opioids or by stress-induced analgesic mechanisms. = There=20 appears to be a specific effect of hypnotic suggestions on pain=20 transmission and registration at several levels of the nervous = system=20 (Patterson & Jensen, 2003).

The frontolimbic attention system has been implicated in = hypnotic=20 analgesia (Rainville et al., 1999). It is believed that hypnotic = pain=20 control involves an active process of acknowledging the pain and=20 subsequently, focusing attention away from the pain. On the basis = of=20 recent research (De Pascalis, Magurano, Bellusci, & Chen, = 2001;=20 Faymonville et al., 2003; Kropotov, Crawford, & Polyakov, = 1997), it=20 has been hypothesized that moderate to highly hypnotizable persons = have=20 more efficient frontolimbic attentional systems that allow them to = actively engage attentional ability and disattend from pain.

Can Anyone Be Hypnotized?

The effectiveness of hypnotic suggestions for pain relief = depends on=20 the individual's hypnotic responsiveness or hypnotizability = (Hrezo, 1998).=20 Hypnotizability is a personality trait that is normally = distributed and=20 can be measured using standardized scales (Raz & Shapiro, = 2002).=20 Individuals who can sustain attention in the face of distractions = and=20 generate vivid visual imagery are often moderate to highly = hypnotizable.=20 Highly hypnotizable individuals can dramatically reduce their = feelings of=20 sensory pain and suffering during hypnosis, whereas less = hypnotizable=20 persons can usually reduce the suffering component of pain to a = great=20 extent (Hrezo, 1998). Hypnosis has a place in pain treatment for = both low=20 and highly hypnotizable persons.

Because hypnotic pain control is dependent on the individual's = ability=20 and active participation in hypnotic strategies, hypnotic = analgesic=20 techniques are consistent with current self-management approaches = for pain=20 control. Self-hypnosis is often a valuable addition to the = treatment of=20 many pain syndromes, including headaches and cancer. Even when the = pain is=20 not dramatically reduced, individuals generally report an increase = in=20 self-efficacy after mastering hypnosis (Lynch, 1999; Patterson = &=20 Jensen, 2003).

What Is the Hypnotic Process an Individual Goes Through?

Hypnotic analgesia techniques usually concentrate on = diminishing the=20 individual's experience of pain and suffering. First, the = individual is=20 guided into a state of relaxation and focused attention using a = "hypnotic=20 induction" similar to becoming fully engrossed in a movie. Next, = the=20 clinician helps the individual to restructure the pain experience = through=20 the use of imagery and verbal instructions or suggestions for = comfort and=20 alteration in physical sensations. Unlike other psychologic = techniques for=20 pain management, hypnotic responses are generally experienced as=20 effortless.

When hypnosis is used for chronic or enduring pain, treatment = begins=20 with hetero-hypnosis, hypnosis of one person by another. The = clinician=20 induces a hypnotic state and provides specific suggestions for = pain=20 relief. A brief cue for re-entering hypnosis (e.g., an eye role) = is=20 provided. If continued treatment is necessary, the clinician = frequently=20 will teach the patient self-hypnosis and will be asked to practice = this=20 technique daily. When individuals have learned self-hypnosis, they = can=20 often transfer their newly found attentional abilities outside of = a=20 hypnotic state.

Hypnosis consists of diverse levels of trances that vary by = individual=20 and within the hypnotic session. Levels range from alert, to = daydreaming,=20 loss of awareness of surroundings, or the deep trance, when the = individual=20 actually feels the activity or image. Details of hypnotic = procedures and=20 suggestions will differ depending on the goals of the practitioner = and the=20 purposes of the clinical or research endeavor. Traditionally = procedures=20 involve suggestions to relax, although relaxation is not necessary = for=20 hypnosis and a wide variety of suggestions can be used including = those to=20 become more alert.

Hypnosis and the Older Adult

Little research specifically addressees the use of hypnosis = with the=20 older adult. Only three studies (Ashton et al., 1997; Gay et al., = 2002;=20 Lang et al., 1996) were found that reported a mean age of = participants of=20 60 to 69 years.

However, these studies were not focused specifically on the = older adult=20 or on the benefits to this cohort. Ashton et al. (1997) found that = patients who were taught self-hypnosis before coronary artery = bypass=20 surgery (mean age was 64 years in the hypnosis group) needed less=20 postoperative pain medication and had less postoperative anxiety = and=20 tension compared with a control group. The self-hypnosis group = also=20 reported less depression, anger, fatigue, and confusion after the = surgery.=20 When comparing hypnosis and relaxation, Gay et al. (2002) reported = that=20 older adults with osteoarthritis who were in the hypnosis group = (mean age=20 was 64 years in the hypnosis group) were effective in reducing the = amount=20 of analgesic medication needed to control arthritic pain. Lang et = al.=20 (1996) further supported the use of hypnosis in the older adult = when=20 self-hypnotic relaxation was used during interventional radiologic = procedures (mean age was 69 years old in the hypnosis group). = Participants=20 used less midazolam plus 25 =B5g of fentanyl through a = patient-controlled=20 analgesia/sedation, reported less pain, and had less oxygen = desaturations=20 during the procedures, as well as less interruptions during the = procedures=20 for hemodynamic instability. Although these studies did not = directly=20 address the use of hypnosis in the older adults, the benefits of = this=20 intervention are documented.

Implications for Pain Management Using Hypnosis in the Older=20 Adult

Hypnosis may provide a complementary or alternative approach = for pain=20 management in the older adult. The health care provider should be = aware=20 that this successful treatment is no longer considered mystical or = voodoo=20 but can provide safe, cost-effective outcomes in patients with = chronic=20 pain for whom traditional Methods of treatment have stopped = working.

Health care providers who work in adult day care centers, = senior=20 centers, hospices, continuing care retirement centers, assisted = living=20 facilities, or nursing facilities can influence the use of = hypnosis in=20 their facilities. With knowledge that it is a safe and effective=20 intervention for pain management in the older adult, the = availability of=20 hypnosis can be included easily in daily activities for the older=20 adult.

Careful consideration needs to be given when choosing a = hypnotist to=20 work in any health care setting. Hypnosis and hypnotic therapies = are not=20 regulated in most states, and hypnotherapists usually have no = state=20 licensure requirements. The "lay" hypnotist should be trained in=20 hypnotherapy with no less than 100 hours of classes. They lack = medical,=20 psychologic, dental, or other professional training. The = professional=20 hypnotist is a licensed health care provider who has 7 to 9 years = of=20 university coursework plus additional supervised training. = Information=20 should be provided to patients on how to choose a hypnotherapist ( = Table 2 ).

It is also important for health care providers to be aware of=20 professional organizations that can provide educational and = research=20 information for patients interested in hypnotherapy. A list of=20 professional hypnosis organizations is provided in Figure 2. The = goal of=20 these organizations is to provide an opportunity to learn from and = interact with members of multiple disciplines as well as to = improve=20 clinical practice and research. These professional organizations = are made=20 up of registered nurses, social workers, dentists, psychologists,=20 psychiatrists, and other physicians who are dedicated to the = highest level=20 of scientific inquiry and the conscientious application of = hypnosis in a=20 variety of health care settings for the older=20 adult.

Figure 2.
Professional hypnosis organizations.

Pain in the older adult is often minimized, mistreated, or=20 misdiagnosed. Left untreated, outcomes of chronic pain can lead to = depression, social isolation, sleep problems, and difficulty = performing=20 activities of daily living. The benefits of complementary and = alternative=20 therapy in the older adult are often ignored, yet, this group is = very open=20 to many of these interventions. When used appropriately, hypnosis = may be a=20 useful intervention to improve pain management in the older = adult.

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Table 1. Myths About Pain in Older Adults

Table 2. Tips on Choosing a Hypnotherapist

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Acknowledgements

This article was developed with support from Daniel I. Galper, = Ph.D., a=20 licensed clinical psychologist with a specialization in behavioral = medicine. Dr. Galper has been actively involved in the field of = CAM as=20 both a clinician and researcher. He completed 2 years of = postdoctoral=20 clinical training at the University of Virginia School of Medicine = using=20 hypnosis and other "mind=96body" techniques (e.g., biofeedback) to = assist=20 patients with cancer, diabetes, and chronic pain. He also = completed a=20 2-year National Institutes of Health-sponsored Post-Doctoral = Research=20 Fellowship at the University of Virginia Center for the Study of=20 Complementary and Alternative Therapies. Dr. Galper is currently a = Senior=20 Research Associate at the Depression and Anxiety Disorders = Program,=20 University of Texas Southwestern Medical Center at = Dallas.

Reprint Address

Norma Cuellar, RN, University of Pennsylvania School of = Nursing, 441=20 Edgewood Drive, Ambler, PA 19002. E-mail: ncuellar@nursing.upenn.edu=

Norma G. Cuellar, DSN, RN, Pennsylvania = School of=20 Nursing, Philadelphia, Pennsylvania

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