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Care of the Aging Patient: From Evidence to Action |

Management of Persistent Pain in the Older Patient A Clinical Review

Una E. Makris, MD1,2; Robert C. Abrams, MD3,4; Barry Gurland, FRCPhysicians, FRCPsychiatry5; M. Carrington Reid, MD, PhD4
[+] Author Affiliations
1Department of Internal Medicine, Division of Rheumatic Diseases, UT Southwestern Medical Center, Dallas, Texas
2Department of Medicine, Division of Rheumatology, Veterans Administration Medical Center, Dallas, Texas
3Department of Psychiatry, Weill Cornell Medical College, New York, New York
4Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York
5Stroud Center, Columbia University, New York, New York
JAMA. 2014;312(8):825-837. doi:10.1001/jama.2014.9405.
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Importance  Persistent pain is highly prevalent, costly, and frequently disabling in later life.

Objective  To describe barriers to the management of persistent pain among older adults, summarize current management approaches, including pharmacologic and nonpharmacologic modalities; present rehabilitative approaches; and highlight aspects of the patient-physician relationship that can help to improve treatment outcomes. This review is relevant for physicians who seek an age-appropriate approach to delivering pain care for the older adult.

Evidence Acquisition  Search of MEDLINE and the Cochrane database from January 1990 through May 2014, using the search terms older adults, senior, ages 65 and above, elderly, and aged along with non-cancer pain, chronic pain, persistent pain, pain management, intractable pain, and refractory pain to identify English-language peer-reviewed systematic reviews, meta-analyses, Cochrane reviews, consensus statements, and guidelines relevant to the management of persistent pain in older adults.

Findings  Of the 92 identified studies, 35 evaluated pharmacologic interventions, whereas 57 examined nonpharmacologic modalities; the majority (n = 50) focused on older adults with osteoarthritis. This evidence base supports a stepwise approach with acetaminophen as first-line therapy. If treatment goals are not met, a trial of a topical nonsteroidal anti-inflammatory drug, tramadol, or both is recommended. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. Careful surveillance to monitor for toxicity and efficacy is critical, given that advancing age increases risk for adverse effects. A multimodal approach is strongly recommended—emphasizing a combination of both pharmacologic and nonpharmacologic treatments to include physical and occupational rehabilitation, as well as cognitive-behavioral and movement-based interventions. An integrated pain management approach is ideally achieved by cultivating a strong therapeutic alliance between the older patient and the physician.

Conclusions and Relevance  Treatment planning for persistent pain in later life requires a clear understanding of the patient’s treatment goals and expectations, comorbidities, and cognitive and functional status, as well as coordinating community resources and family support when available. A combination of pharmacologic, nonpharmacologic, and rehabilitative approaches in addition to a strong therapeutic alliance between the patient and physician is essential in setting, adjusting, and achieving realistic goals of therapy.

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Figure 1.
Treatment Algorithms for Nociceptive and Neuropathic Pain Disorders in Older Adults

aRecommend use of oral nonsteroidal anti-inflammatory drugs (NSAIDs) in appropriate patients for selected situations (eg, acute-on-chronic pain flare, brief rehabilitation period, acute injury).

bConsider combination therapy when possible (eg, acetaminophen + serotonin-norephinephrine reuptake inhibitor) for the treatment of nociceptive and neuropathic pain.

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Figure 2.
Approach for Monitoring Pain Management and Adjusting Medication for Older Adults Already Taking Analgesic Medications

aObtain both patient and proxy data whenever possible: assess for history and physical examination evidence of gait disturbance, falls or near falls, mental status changes (confusion, lethargy, mental slowing, attention problems); change in gastrointestinal or genitourinary function: assess for other adverse effects based on knowledge of adverse-effect profile of prescribed medication(s).

bRecommend routine screening for misuse/abuse behaviors, periodic urine testing; consider treatment agreements. Review data from prescription drug monitoring programs regularly in states that have them.

cInitiation indicates selection of starting dose and frequency of administration; titration indicates adjustment of medication dose to achieve optimal level of analgesia (see Table 1).

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