Proposed Algorithm to Diagnose, Treat Neuropathic Pain

An article recently published in Drugs & Aging details an algorithm designed to improve the diagnosis and treatment of neuropathic pain in elderly patients, with special guidance pertaining to those with communication or cognitive difficulties.¹

In addition to the high rate of failure associated with the treatment of neuropathic pain in general, its diagnosis and management in older adults pose unique challenges.

“Neuropathic pain is difficult to detect, evaluate, and treat in elderly persons, and is often missed or neglected in the elderly, especially if they have cognitive disorders,” Gisèle Pickering, MD, PhD, DPharm, a clinical pharmacologist at the Faculty of Medicine and University Hospital of Clermont-Ferrand in France, told Clinical Pain Advisor.

While pain assessment typically relies on self-report, the higher prevalence of cognitive impairment or dementia in the elderly can make communication difficult.

Complicating treatment planning, geriatric patients often have comorbidities and are more likely to be taking several medications, placing them at higher risk of drug-drug interactions and other adverse outcomes. These issues are becoming more pressing with the increase in global average life expectancy.

Dr Pickering is part of the Doloplus committee², a team of practitioners representing multiple disciplines such as geriatricians, pharmacologists, and pain clinicians, each with 10-30 years of relevant pain treatment experience.

The group developed the algorithm through a year-long process of reviewing relevant published data, sharing their own clinical experiences, and considering feedback from geriatric and pain societies.

The algorithm consists of 4 areas:

1. Detection and Diagnosis

Observation is an essential element in detecting neuropathic pain in older adults, including those who are not cognitively impaired.

Clinicians should look for “any warning signs of the presence of chronic pain with neuropathic characteristics,” according to the authors. “Any change of behavior in elderly patients, especially those with communication disorders impacting pain expression, should lead the physician to suspect the presence of pain,” they wrote.

Additionally, the clinician should review the patient’s file and inquire with family members to identify any relevant behavior or medical history. The clinical exam should be particularly concerned with identifying symptoms of allodynia and hyperalgesia.

2. Evaluation

Numerical or verbal rating scales, as well as open-ended questions are recommended for the general evaluation of pain in elderly patients.

If the patient is able to self-report, clinicians can use a NP scale. For patients with impaired communication, the validated behavioral scales Algoplus and Doloplus may be used. Quality of life and functional status should also be assessed.

3. General Guidelines for Neuropathic Pain Management

The physician should design a treatment plan based on a thorough evaluation of the patient. The authors recommend a multimodal approach that includes evidence-based pharmacological and non-pharmacological strategies.

They review various types of medications that may be prescribed, including opioids, which are now considered a third-line treatment due to their high abuse potential and mortality risk.

4. Reevaluation of Neuropathic Pain

Efficacy of treatment and adverse events should be monitored with input from the patient’s caregivers and healthcare team, and the treatment plan should be revised as necessary.

Though this algorithm may be useful in current practice, it has not been validated in real-life settings. Dr Pickering said the algorithm must now be validated in a larger population, and the Doloplus group plans to do so with a prospective study.