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Written by

Dr Aza Abdulla Dr Aza Abdulla is consultant physician and geriatrician, Princess Royal University, King’s College NHS Foundation Trust, UK

Dr Wisam Ali Dr Wisam Ali is a consultant anaesthetist and pain specialist, Denmark Hill Campus, King’s College NHS Foundation Trust, UK

Management of pain in older people

Published 4 March 2016

In the second of two articles on pain in older people, Dr Aza Abdulla and Dr Wisam Ali discuss various approaches including pharmacotherapy, interventional therapies, psychological interventions and physical activity

Key learning points

  • Pharmacotherapy should be frequently assessed and reviewed.
  • Interventional therapies may be a useful adjunct.
  • Psychological interventions and physical activity should be considered as part of holistic management.
  • Combining pharmacological and non-pharmacological strategies may alleviate pain for many patients.

One important concept in pain management is that there is no ‘magic’ drug that will control pain effectively in every patient. Clinicians should appreciate that treatment may be ineffective and both patients and their families should be informed and aware of the possibility of treatment failure.1

Pharmacotherapy

Paracetamol

The practice of starting treatment with paracetamol (acetaminophen) is being challenged on grounds of poor efficacy and risk of abnormal liver function tests.2 Until further studies are reported, paracetamol can be used, albeit perhaps at a lower dose in frail older people.3 It is important to remember that paracetamol is, at best, only a mild analgesic.

NSAIDs

There is general consensus that oral NSAIDs should no longer be recommended as analgesics in older people. Even in patients with no history of gastrointestinal problems, heart failure or hypertension, they should be used for a few days only if necessary, and always with gastroprotection. In contrast, topical NSAIDs are effective and useful in localised musculoskeletal pain, notably knee osteoarthritis, with a potential reduction in side effects. In addition, capsaicin cream and lidocaine patches applied to site of pain are useful for localised neuropathic pain.4

Opioids

The choice of particular opioid depends on the clinician’s experience. In carefully selected and monitored patients, opioids may provide effective pain relief as part of a pain management strategy, although careful dose titration may be required.4 Patients with continuous pain may be treated with modified release oral or transdermal opioid formulations, in order to achieve relatively constant plasma concentrations.4 The convenience of a transdermal formulation may also reduce also administration and staff time in residential and nursing homes.4 However, with all opioids it is important to monitor for somnolence, confusion and constipation. Prescribing laxatives regularly alongside an opioid is now commonplace.4

While a ‘start low, go slow’ approach is always recommended, there is the risk that older patients left in pain with limited functioning for a long period of time may not return to their previous functional ability. Frequent assessment is recommended, either face-to-face or through a service such as a nurse-run telephone clinic, where the clinician can monitor patient response and recommend adjustment of dosage.

Interventional therapy

If pain is localised, then it is a plausible option to treat with a local interventional approach, especially if systemic treatment risks undesirable side-effects such as constipation, drowsiness, lethargy or confusion.

Interventional therapies range from intra-articular corticosteroid injection, as the treatment of choice in a patient with recurrent attacks of acute pseudogout of the knee, to nerve block in acute herpes zoster and postherpetic neuralgia, to epidural steroid injections for spinal stenosis and radicular symptoms.4 These are all of proven value.4 However, the success rate of the latter procedures is operator dependent and relates to the approach and technique used (image guided versus blind approach).

Regional techniques, either as the sole method of treatment or as adjuvant analgesia, are well tolerated in the older population, and may limit the use of opioids.5

Where the evidence exists, interventional techniques should be considered, especially in patients with chronic pain when pharmacological treatments are ineffective or not tolerated.

Physical activity

The evidence base supports the use of exercise programmes that comprise strengthening, flexibility and endurance activities to increase physical activity, improve function and reduce pain. An exercise programme should be considered as a component of management, either as a standalone option or in combination with other treatments.4 Physiotherapists are the experts in this field and a programme can be developed jointly with the referring clinician, taking patient preference into account.

Complimentary therapies like conventional TENS and acupuncture, individually or combined, may be effective in reducing pain intensity and improving quality of life.4 These approaches can be used as an adjunct to the pharmacological approach.

Psychological interventions

There is growing evidence that psychological interventions, notably cognitive behavioural therapy (CBT), may be effective in reducing chronic pain and improving disability.4 Other treatment approaches, such as relaxation techniques, mindfulness and meditation, teach the patient how to adapt to chronic pain through acquiring self-regulation skills. This facet of management is under-utilised and should be considered as an adjunct to pharmacological intervention and/or other modalities.6

No recommendation on the management of pain in older people is complete without certain cautions. Firstly, it is important not to dismiss pain in older people as simply due to general wear and tear of ageing or osteoarthritis. Recent onset back pain or headache, especially if associated with other complaints, for example fever in the former, or confusion in the latter, loss of appetite and weight loss, should always be investigated. This is especially the case when lasting for more than four to six weeks. Neoplasia, some haematological malignancies and vasculitides are more common in older people and early diagnosis is important.

Conclusion

It is important to expand clinicians’ repertoires beyond basic medication to consider, where appropriate, alternative pain relief options including interventional therapies, psychotherapy, physiotherapy and exercise. Combining pharmacological and non-pharmacological strategies has been found to enhance the relief of pain for many patients.4,7 Indeed, often more than one treatment modality may be required for satisfactory pain control.

  • Dr Aza Abdulla is consultant physician and geriatrician, Princess Royal University, King’s College NHS Foundation Trust, UK and Dr Wisam Ali is a consultant anaesthetist and pain specialist, Denmark Hill Campus, King’s College NHS Foundation Trust, UK 

References

  1. Moore A, Derry S, et al. British Medical Journal 2013;346:f2690.
  2. Machado GC, Maher CG, et al. British Medical Journal 2015;350:h1225.
  3. Mitchell SJ, Hilmer SN, et al. Journal of Clinical Pharmacy and Therapeutics 2011;36(3):327–335.
  4. Abdulla A, Adams N, et al. Age and Ageing 2013;42 Suppl 1:i1–57.
  5. Halaszynski TM. Current Opinion in Anaesthesiology 2009;22(5):594-599.
  6. McGuire BE, Nicholas MK, et al. Current Opinion in Psychiatry 2014;27(5):380–384.
  7. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Journal of the American Geriatrics Society 2009;57(8):1331–1346.

Further reading

Date of preparation: February 2016; MINT/PAEU-15036