Management of Chronic Musculoskeletal Pain in the Elderly: Dilemmas and Remedies

Abstract

Pain in Perspective 94percent of community dwelling adults aged 60 years or above have been found to experience pain and this number increases to 45-80% in the nursing home population with analgesics being used in 40% to 50% of residents [1,[13][14][15][16][17][18][19]. Brown et al report higher percentage and state that more than 90% of the elderly living in the community experienced pain within the past month [6]. Given the prevalence of chronic pain, its impact on health, and its costs, which approach $100 billion annually, chronic pain represents a major public health issue [20].While the existence of acute pain remains approximately the same across the adult life span, there is an age-related increase in the prevalence of chronic pain at least until the seventh decade of life [13,15]. Approximately 57% of older adults report experiencing pain for 1 or more years compared with less than 45% of younger people. Furthermore, long-term care data indicate that over 40% of patients, who were known to have pain at an initial assessment, had worsening or severe pain at the time of the second assessment 2-6 months later [21]. Chronic musculoskeletal painChronic musculoskeletal pain (CMP) is the most common, non-malignant disabling condition that affects at least one in four older people [22,23]. The most musculoskeletal pain in the joints of the upper and lower extremities, especially hips, knees, and hands, is associated with the degenerative changes of osteoarthritis. Older adults may also develop tendonitis and bursitis, as well as inflammatory joint and muscle disease [24]. The most common painful musculoskeletal conditions among older adults are osteoarthritis, low back pain, fibromyalgia, chronic shoulder pain, knee pain, myofascial pain syndrome and previous fracture sites [7,23,25].It is reported that the most common causes of pain identified in nursing home patients included arthritis and previous fractures. Arthritis alone affects well over 20 million Americans with an increase to 40 million expected by 2020. Twenty-nine percent of Medicare patients in nursing homes with a fracture in the prior 6 months suffer with daily pain [13]. Also surgical procedures are more frequently performed on older people. In the Medicare population in the United States for example, rates of total joint replacement surgery for patients with severe hip or knee osteoarthritis are more than doubled between 1988 and 1997. Over the same time period, rates of spine surgery in Medicare patients increased by 57% [23]. Chronic low back pain (CLBP) is one of the most common, poorly understood, and potentially disabling chronic pain condition s i n o l d e r a d u l t s [ 2 6 ] . M a n y o l d e r a d u l t s r e m a i n q u i t e functional despite CLBP, and because age-related co-morbidities often exist independently of pain, the unique impact of CLBP is unknown [27]. The Framingham Study (1992-1993 reported 63% of women pain in one or more regions, compared to 52% of men. Widespread CMP was more prevalent among women than men (15 versu...