Management of Persistent Pain in the Older Patient

Abstract

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.

Immunosuppressive agents are associated with peptic ulcer bleeding

“…NSAIDs are commonly used for rheumatic diseases and persistent pain due to orthopedic diseases (5,6). Rheumatic diseases have an autoimmune basis and affect connective tissue (6,7).…”

Osteoarthritis: Management of Patients and Compliance to Treatment

“…Недооценка низкого комплаенса, особенно при боле-вом синдроме, у пациентов с ОА ведет к неправильной тактике лечения: коррекции терапии, увеличению доз препаратов и необоснованной госпитализации [17,18].…”

The prescription opioid epidemic: an overview for anesthesiologists

“…8,34,[41][42][43][44] As a result, a recent clinical review recommends initiating long-term opioid therapy only when patients have moderate to severe pain leading to substantial impairment in daily living and when all other treatment modalities have failed. 45 This is not a recommendation founded on demonstrable evidence of benefits exceeding harms. Moreover, these guidelines are often not observed in clinical practice, as many practitioners continue to initiate opioids as a first-line therapy in the treatment of various chronic pain syndromes.…”