According to the NIH a majority of elderly persons today have significant pain problems that go undertreated. Pain will always be one of the most pervasive and elusive issues to treat in patients – especially for the elderly. The key is that older adults are not simply an older version of younger pain patients; there are many added factors to consider when treating older adults with chronic pain, with the goal to create the least amount of side effects with any treatment rendered.
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Before we consider medication and treatment for any medical condition, it is critical to step back and consider the big picture when addressing pain symptoms, notes Philippe Berenger, MD, of Cleveland Clinic’s Department of Pain Management. “We need to identify the social and psychological context in which our patients find themselves,” he explains. “We should, but often don’t, explore with our patients the issues of anxiety and depression that coexist and exacerbate pain.”
He notes that cognitive interventions for adjustment to pain can be used in the elderly more often than they have been employed in the past. He suggests talking with patients about activity and mindful meditation for improved brain function and suppression of nerve pain.
As people age, we have to consider the impact of loss of independence, the loss of a spouse or partner, and the financial changes they are experiencing. “Once we’ve determined how well a patient is staying engaged in life and talk with them about their role in their own pain management—from the social aspect to regular exercise—then we can consider the least invasive way to address their pain,” Dr. Berenger says.
Conditions causing pain
Aside from arthritis, the most common pain conditions in older adults are myofascial pain syndrome, chronic low back pain, lumbar spinal stenosis and fibromyalgia syndrome.
Myofascial pain syndrome (MPS) is stress-related muscle tension often caused by overuse. Frequent localizations include piriformis muscle, cervicogenic headache, trochanteric bursitis and the iliotibial band, upper and lower back pain and trapezius. Some underlying factors to identifying this are poor posture and shoulder girdle dysfunction. It can be helped through manual therapy and trigger point injection as well as building muscle resilience through stretching and strengthening. Chronic low back pain is often associated with sacroiliac pain, hip osteoarthritis, fibromyalgia or leg length discrepancy (primary or secondary to THA/TKA).
One in five asymptomatic older adults over age 65 have moderate to severe lumbar canal stenosis. The surgical failure rate is one in three with risk factors being osteoporosis, diabetes, depression and associated hip OA. Decompressive laminectomy to relieve pressure on the spinal roots is the most common treatment when the condition becomes serious, however, less than 20 percent of elderly patients experience decreased LBP or leg pain following the procedure.
The fourth most common condition to cause pain for the elderly, fibromyalgia, is frequently associated with widespread pain in patients with osteoarthritis.
When prescribing medications
It’s important to keep in mind the age-related changes in pharmacokinetics and the dynamics, including increased volume of distribution (more fat, less muscle) and decreased renal function and clearance. Of course the first line of medication treatments often include the nonopioid pain agents like NSAIDs, acetaminophen, membrane stabilizers and tricyclic agents, however, many of these can have significant side effects in the older patient and may not be tolerated.
We should introduce one medication at a time, Dr. Berenger cautions, and consider any new symptom as being medication-related. “We need to strike a balance between a medications theoretical indication and its efficacy and tolerability in the older patient,” Dr. Berenger advises. “We also need to review potential side effects and interactions of herbal supplements with other medications.”
Two of the most common supplements taken by older adults are gingko biloba for anxiety and St. John’s Wart for depression. When taken with warfarin, gingko biloba can increase the risk of bleeding. And when taken with any selective serotonin reuptake inhibitor (SSRI), St. John’s wart can lead to serotonin syndrome. The American Geriatric Society compiled a list of medications (Beers list), which highlights drugs that may be high risk in the older patient population. These include benzodiazepines, diphenhydramine (Benadryl®) and opioids.
Pain processing changes related to age include a decrease in the number of sensory fibers, impairment in early warning functions of nociceptive A delta fibers, brain changes that lead to loss of volume, senile plaques and neurofibrillary tangles intercepting neuronal tracts. There are changes in the availability of neurotransmitters with an age-related decrease in serotonin, dopamine and other monoamines so that there is not enough available for central pain modulation. In these cases analgesics are necessary.
Dementia and pain
With up to 15 percent of patients over 65 experiencing brain changes from Alzheimer disease (AD) and dementias, we must keep this in mind too. AD affects the medial pain system (orbitofrontal cortex, amygdala, hypothalamus, posterior insula) causing disruption in a patient’s ability to evaluate and judge the pain they are perceiving. AD has a late effect on the lateral pain system (primary somatosensory cortex, inferior parietal cortex), leading to difficulties in localizing and judging the quality of the pain they are feeling.
There are some confounding scenarios when several pathologies coexist such as AD and Parkinson’s (which causes rigidity/spasticity) and AD and myelopathy (which causes gait disturbance, spasticity and pain).
Patients with cognitive impairment report less pain than intact older adults, however there is no evidence that cognitive impairment reduces the ability to feel pain. These patients may express their pain through facial expression and body movements such as bracing, rocking, pacing, rubbing or posturing.
Dr. Berenger stresses the importance of motivating older patients to stay as engaged and active as possible, while minimizing use of medications. These positive lifestyle choices can reduce, alleviate and prevent pain states as people age and ultimately save healthcare costs. And as our population ages, this has never been more important.