Treatment of Persistant Pain in Olders Adults –

Up todate
• The last 15 years have begun to pay attention to Pain Management !

• Because: Medical Development ➡️ New surgical procedures & treatments

• Development ➡️ the opportunity to live longer, but ⬆️ increased pain in the short
term or longer.

• Socio-cultural role: Geriatrics ➡️ increased chronic conditions, including rheumatoid

arthritis, osteoporosis, osteoarthritis and pain due to blocked arteries.

• Social tolerance for pain ⬇️ & physical discomfort ⬇️

Socio-cultural role in Olders Adults – Up todate

• >75 years: growing with numbers of the frailest, most pain-ridden.

• >85 years: increasing the most rapidly.
• >50% of community-dwelling(thuiswonende) older adults report:
1. Pain that interferes with normal function
2. At least half of half of nursing home residents reports on a daily basis.
• Contributors to Pain &/ impact treatment response:
1. Medical psycholological
2. Social comorbidities
3. Environmental factors
 EFFECTS OF CHRONIC PAIN IN OLDER PATIENTS
• Pain may contribute to:
1. homeostenosis(eg the progressive & gradual decline in physiological reserve with
aging) and
2. amplify frailty(kwetsbaarheid)

• Persistent pain may be associated with:

• Impaired physical function, falls, diminished appetite, dysmobility, sleep disruption,

depression and anxiety, agitation, and delirium, as well as more subtle decrements in
cognitive function.

• On the other hand, many older adults function well despite persistent pain, and
the degree to which pain interferes with function is largely related to the
individual's burden of biopsychosocial comorbidities [17].
 GENERAL APPROACH
• Persistent pain: Pain that continues beyond the expected time of healing,/for 3-6.
• Prescribing effective treatment starts with an accurate & comprehensive history that

1) def. the older adult's"pain signature" (the parameters affected by pain & the severity of their impact),
2) highlights key comorbidities that contribute to pain or influence its treatment, and
3) identifies treatment targets.

• Older adults may under-report the severity of pain because of

1. misconceptions that pain is a normal part of aging,
2. a tendency toward stoicism(the endurance of pain or hardship without a display of feelings and without
complaint.), or fears of addiction.
3. The coexistence of sensory (eg, vision and/or hearing deficits) and/or cognitive impairment also
may make the evaluation of pain more challenging in the older patient.
DIAGNOSE: (1) History & review of systems
(2) Physical examination
(3) Imaging
 Identifying physical contributors to persistent pain
Important:

1. To approach the older adult with any type of chronic pain as an older adult first and a
patient with pain second.

2. A basic principle of geriatric medicine is that pathology can make the patient vulner-
able to other stressors, which may be the treatment targets, rather than the
pathology itself.

3. For example, a patient with LBP may have degenerative disease of the lumbar spine,
but the important treatment target may be co-existent depression.
 TREATMENT OPTIONS

1. CONSERVATIVE: Medication, Physio Therapy, TENS, Acupuncture, TP injection

2. INTERVENTION: Radio Frequency

Drug prescribing for older adults
• Optimizing drug therapy is an essential part of caring for an older person.

• The process of prescribing a medication is complex and includes:

• deciding a drug’s indication,
• choosing the best drug,
• determining a dose and schedule depending the patient's physiologic status,
• monitoring for effectiveness and toxicity,
• educating the patient about expected side effects, & indications for seeking
consultation.
 Avoidable adverse drug events (ADEs)

• The serious consequences of inappropriate drug prescribing.

• Prescribing for older patients presents unique challenges.
• Use medications with special caution because of age-related changes in
pharmacokinetics. As examples in older adults :
• The volume of distribution for diazepam ⬆️, &
• The clearance rate for lithium ⬇️.
• In pharmacodynamic perspective: ⬆️ age ➡️ sensitivity ⬆️ to the effects of certain
drugs, including benzodiazepines and opioids .
• Age-related changes in hepatic function
 MEDICATION USE BY OLDER ADULTS

• Medications (prescription, over-the-counter (free), & herbal preparations) are widely

used by older adults.

• Prescription medications — A survey in the US of sampling of 2206 (62 - 85 years)

home interviews & use of medication in 2010 and 2011:
• 87 percent at least one prescription
• 36 percent 5/more prescription
• 38 percent : over-the-counter medications.

• In a sample of Medicare beneficiaries discharged from an acute hospitalization to

a skilled nursing facility, patients were prescribed an average of 14 medications,
including over one-third with side effects that could exacerbate underlying geriatric
syndromes.
 Pharmacologic therapy & interventions
• Pharmacologic interventions increased risk of toxicity.
• Pharm therapy: begin with the routes of administration, medications, and doses ,
begin with the routes of administration, medications, and doses, preferable to
systemic medications (eg, oral analgesics) when applicable. In most cases a non-
opioid medication is the initial choice.
• Reduce Doses of opioid medications in older adults and titrated slowly to effect, with
close monitoring for side effects. Suggest decreasing the initial dose:
• 25 % for a 60-year-old patient.
• 50 % for an 80-year-old)
• 40-year-old normally receive, but at the same intervals
• Patients with mild to moderate dementia can often reliably report pain. Before treating
it, the healthcare provider must validate that it is associated with suffering, and not
simply perseveration or the expression of distress related to another unmet need.
• Patients with advanced dementia may be unable to communicate the need for
analgesic medications. In such cases, an empiric analgesic trial accompanied by
careful documentation of outcomes (eg, decreased agitation) may be warranted.
 NONPHARMACOLOGIC TREATMENTS

• NON Pharm.are often beneficial, in place of / in addition to pharm. treatments.

• Wide array of treatments:

• the physical interventions ( physical ther., acup., chiropractic manipul., massage, and others)
• the psychoeducational interventions (cognitive-behavioral therapy, meditation, and patient
education).
• Many of these therapies are low cost, with minimal side effects, and may decrease the
dose and therefore the risk from any needed medications.

• Benefits were greatest with group-based rather than individual therapy.

• The efficacy of nonpharmacologic treatments does not appear to differ in older adults
compared with other ages.
 PHARMACOLOGIC TREATMENTS
• INDIC: Functional impairment/diminished quality of life despite nonpharm. treatments
• Routes of administration, medications, and doses should be selected that are the least
likely to lead to toxicity, side effects, or interactions with other medications.
• In most cases, non-opioid medications are preferred to opioids for non-cancer pain,
due to side effects in older patients.
• Analgesics should be initiated at the lowest effective dose.
• Localized use of medication (eg, joint injections, trigger point injections) may be
preferable to systemic medications (eg, oral analgesics) when applicable.
• Non-opioids : dependent upon an accurate evaluation of the cause of the pain and
the type of chronic pain syndrome.
• Topical and injected analgesics:
benefit of avoiding systemic adverse effects, and thus are a good option in the
older patient.
Injection therapy (eg, joint injections, trigger point injections) may be preferred to
systemic medications to decrease toxicity and side effects in older adults
 PHARMACOLOGIC TREATMENTS

• Acetaminophen: the first-line treatment in the management of mild persistent pain in

the older adult because of its greater safety compared to other analgesics, particularly
NSAIDs.

• However, acetaminophen lacks significant antiinflammatory properties, making

acetaminophen less effective for chronic inflammatory pain than NSAIDs

• A max. acetaminophen dose <3 grams in 24 hours is a prudent(voorzichtig) approach,/< 2 g/d

in frail patients ( > 80 years of age, & those who use alcohol on a regular basis).
• The American Geriatric Society guideline: <4 g /d.

• Patients receiving both acetaminophen and cytochrome P450 inducing drugs are at increased
risk of liver problems.
 PHARMACOLOGIC TREATMENTS

• NSAID’s:In general, only be used briefly (1-2 weeks) during episodes /ncreased
nociceptive pain.

• Older adults, low doses,& the choice of drug tailored to the risk factors for G.I. &C.V.
disease.

• Naproxen: a reasonable choice in patients at risk of cardiovascular disease. Patients

at risk of gastrointestinal toxicity should have a gastroprotective agent prescribed, and
may have a lower risk with use of a nonacetylated salicylate or cyclooxygenase
(COX)-2 inhibitor.

• Risk for coronary and vascular events were increased by COX-2 inhibitors, high-
dose diclofenac, and possibly ibuprofen, but naproxen did not increase risk
 PHARMACOLOGIC TREATMENTS

• Antidepressants: used in the treatment of chronic neuropathic pain include

1. tricyclic antidepressants (TCAs),
2. selective serotonin reuptake inhibitors (SSRIs), and
3. selective noradrenalin reuptake inhibitors (SNRIs),
• all of which have increased side effects in older adults. Reasonable choices
are nortriptyline, desipramine, and duloxetine.
• TCAs are highly anticholinergic, leading to sedation, cognitive dysfunction, and
orthostatic hypotension; anticholinergic effects are most prominent in older TCAs
(amitriptyline),with lower prevalence in the sec.amines (nortriptyline, desipramine).
• All TCAs are included Beers list of potentially inappropriate medications in older adults.
• Extreme caution must be taken in older adults with
1. a seizure disorder or who take medicine that can reduce the seizure threshold (ie, tramadol),
2. cardiovascular disease,
3. uncontrolled narrow-angle glaucoma, (4). hepatic disease, or (5). at increased risk of falls
 PHARMACOLOGIC TREATMENTS
• SSRIs and SNRIs (eg, duloxetine) may be used in the treatment of persistent
neuropathic pain and tend to have fewer cardiovascular and anticholinergic adverse
effects than TCAs.
• However, SSRIs may be associated with a higher fall risk than TCAs in older adults.
• Anticonvulsants — Pregabalin and gabapentin have a better safety profile in older
adults than the other anticonvulsants used for persistent.
• Pregabalin and gabapentin are effective in the treatment of neuropathic pain; the most
common side effects are dizziness, somnolence, fatigue, and weight changes.
• Carbamazepine & Oxcarbazepine should be avoided due to risks of hyponatremia
and syndrome of inappropriate antidiuretic hormone secretion, from which older
adults are already at higher risk [87]. For trigeminal neuralgia, carbamazepine (or
possibly oxcarbazepine) is the treatment of choice; using the lowest effective dose
may decrease the incidence of side effects.
 PHARMACOLOGIC TREATMENTS
• Muscle relaxants such as baclofen, cyclobenzaprine, and methocarbamol may not be
tolerated in older adults due to side effects, including sedation, dizziness,
anticholinergic effects, and weakness.
• They should be avoided for individuals age 65 and older.
Opioids
• Many older adults are reluctant to use opioids because of concerns about addiction.
• Education on the difference between dependence, tolerance, and addiction may
help patients accept opioids when they are indicated.
• Because of the lack of high quality evidence, the prevalence of opioid use disorder in
older adults is unknown.
• Choice and dosing of opioid: oral, liquid form, lozenge(zuigtablet), transdermal patch.
• Dose ⬇️: 25 %for a 60-year-old patient
50 percent for an 80-year-old
Initial dose for a 40-year-old would normally receive, but at the same intervals
 SUMMARY AND RECOMMENDATIONS
• The possibility of an Adverse Drug Event (ADE)
• Clinicians must be alert to the use of herbal and dietary supplements by older patients,
• Various criteria sets exist identifying medications: prescribed with great caution,
consider each patient's individual situation, and best clinical judgment
• Clinicians: such as statins, that could provide benefit for older adults, better avoiding
overprescribing of inappropriate drug therapies. Because of financial constraints and
unavailability of prescribed doses: medication underutilization.
• ADEs: 4 X many hospitalizations in older >>>> younger, adults. Preventable ADEs:
Prescribing cascades, drug-drug interactions, and inappropriate drug doses.
• ADEs are a particular problem for nursing home residents; atypical antipsychotic medications
and warfarin are the most common drugs involved in ADEs in this population.
• A stepwise approach to prescribing for older adults: periodic review of current drug
therapy; discontinuing unnecessary medications; considering nonpharmacologic alternative
strategies; considering safer alternative medications; using the lowest possible effective dose;
including all necessary beneficial medications.
 The Screening Tool of Older Person's
Prescriptions (STOPP) criteria
• STOPP includes consideration of drug-drug interactions and duplication of drugs
within a class.
• In 2 studies, STOPP identified a significantly higher proportion of older people
requiring hospitalization as a result of a medication-related adverse event than did
the 2003
• The FORTA (Fit FOR The Aged) list identifies medications rated in 4 categories:
1. clear benefit;
2. proven but limited efficacy or some safety concerns;
3. questionable efficacy or safety profile, consider alternative;
4. clearly avoid and find alternative with ratings based on the individual patient's indication for the
medication.

• The tool, developed in Germany, has undergone consensus validation with a panel of
geriatricians, but studies of its impact on clinical outcomes are ongoing.
 4 of the most common & misdiagnosed conditions
1. Myofascial pain syndrome
• Making a timely diagnosis of myofascial pain in the older adult represents a
pivotal step toward avoiding unnecessary and potentially harmful diagnostic tests
and invasive procedures.
• Myofascial pain as aching, burning, or stabbing.
• The pain often radiates a significant distance from the site of the trigger point,
mimicking radiculopathy or neuropathic pain.
• Common myofascial pain syndromes in older adults include piriformis syndrome
(compression of the sciatic nerve in the region of the sciatic notch as the nerve
comes in close contact with a piriformis muscle that has myofascial dysfunction)
,upper/LBP related to myofascial dysfunction of the paraxial musculature,
trapezius myofascial pain , pseudotrochanteric bursitis (tensor fascia lata
myofascial dysfunction), & post-herpetic myofascial pain
 Treatment of Persistant Pain in Olders Adults

• Identifying and treating the underlying factor(s), responsible for creating muscle
dysfunction
• eg, shoulder dysfunction in the patient with myofascial neck pain, poor sitting
posture in the patient with upper back myofascial pain, or an anxiety disorder in the
patient with myofascial pain at any site.
• Identifying potentially offending medications such as statins is especially important in
older adults.
• Deactivating the trigger point with manual therapy, dry needling, or trigger point
injection
• Building muscle resilience through gentle stretching and strengthening (administered
by a trained physical therapist or another therapist trained in these techniques)
 Chronic low back pain
• associated with multiple physical and psychosocial factors
• In a study of 111 community-dwelling older adults with CLBP,:
• > 80 percent had several physical conditions associated with their pain, most commonly myofascial
pain, sacroiliac joint syndrome, probable hip osteoarthritis (OA), and/or fibromyalgia syndrome.
• Leg length discrepancy following THP /TKP also can precipitate or worsen CLBP.
• Spinal imaging
• Has poor predictive validity for pain.
• Often more helpful in demonstrating absence of disease (ie, compression
fractures, metastatic bone disease, disk space infection) rather than the cause of
pain.
• Should be used judiciously and interpreted cautiously as it is likely to cause undue
anxiety over incidental degenerative pathology, for older adults with CLBP and no
clinical findings suggestive of serious disease,
• Over 95 percent of older adults have degenerative disc &/ facet disease on
radiograph & fewer than half report experiencing LBP during the prior year
 Lumbar spinal stenosis
• Often report leg symptoms with prolonged standing or walking (ie, neurogenic
claudication);
• LBP may or may not be present.
• Imaging required prior to surgical intervention,
• Many older adults have spinal stenosis that is asymptomatic.
• Treatment: a stepped-care approach
• Failure rate: 33%.
• Poor predictions of surgery: hip osteoarthritis, depression, medical comorbidity,
osteoporosis.
• SPORT investigation after decompressive laminectomy experienced, on average:
only 17 percent reduction in back pain and 14 percent reduction in leg pain
 Treatment goals
• Maximize function & quality of life while min-ing adverse effects, associated with treatment.
• Identifying the impact of the pain.
• Total pain elimination is not a realistic goal.
• Ensure the older patient understands 3 general principles in the expectations of optimal PM:
1. Persistent pain is multifactorial, requiring an approach that addresses a variety of etiologies and
includes both pharmacologic and nonpharmacologic strategies
2. Persistent pain is treatable, with improvement anticipated, but it is not curable
3. Although pain may not be totally eliminated, substantial improvement in function is realistic.