Managing Pain in the Elderly With Pharmacologic and Nonpharmacologic Treatments

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A multimodal approach that includes both drug and nondrug modalities for pain is recommended.
A multimodal approach that includes both drug and nondrug modalities for pain is recommended.

LAS VEGAS  -- Both pharmacologic and nonpharmacologic treatments are available as options for clinicians managing pain in their geriatric patients, and guidelines are available to provide direction.

The estimated prevalence of chronic pain in older adults is increasing, ranging from 20% to 50% in primary care, 40% to 60% in those in assisted living facilities, and 50% to 80% of nursing home residents.1 Pain has a significant negative impact on physical functioning and is a major cause of impaired ability to engage in activities of daily living. Elderly patients are more likely to suffer from osteoarthritis and back-related disorders, diabetes, herpes zoster, advanced chronic disease, cancer, and osteoporosis. Other conditions elderly individuals face include fall-related injuries, surgery, and cancer treatments.

“A multimodal approach that includes both drug and nondrug modalities for pain is recommended,” said M. Cary Reid, MD, PhD, director of the Cornell Translational Research Institute on Pain in Later Life in the Division of Geriatric Medicine at Weill Cornell Medical College said at PainWeek 2015.

To treat elderly patients with pain, many clinicians prescribe nonsteroidal anti-inflammatory drugs (NSAIDs), which are the most commonly used analgesics—whether prescribed or over-the-counter treatments—among older adults.2,3 Over the past 15 years, there has also been an increase in opioid consumption among the elderly. Approximately 10% of women age 65 and older are receiving long-term opioid prescriptions.4

Dr. Reid cautioned the audience to be alert to treatment-related harms that put elderly pains at risk.  These include falls or fractures, opioid overdoses, and constipation or obstipation.

Managing pain later in life can be executed by following evidence-based guidelines. According to Reid, the goal is to “generate recommendations that increase likelihood of achieving enhanced patient outcomes.” He also mentioned that clinicians should focus on implementing practical recommendations.

Guideline recommendations for pharmacologic approaches include using acetaminophen as first-line therapy; minimizing use of oral NSAIDs; considering a trial of topical NSAID; and opioid therapy. Additional potential pharmacologic treatment options should be assessed based on the type of pain the patient is experiencing and include anticonvulsants, serotonin norepinephrine reuptake inhibitors, and antidepressants.

Nonpharmacologic treatment modalities have been found to be beneficial for relief of pain symptomatology in older adults and should be considered as adjuncts to medications. Guideline recommendations include cognitive behavioral therapy and exercise approaches, as well as self-management programs and acupuncture.  Dr. Reid further added coping skills therapy, diet/exercise, and motivational interviewing/exercise as drug-free treatment options.

There are 9 management principles that Dr. Reid believes clinicians should follow when managing pain in elderly patients: a multimodal approach; a physical activity program; use of medication combinations; starting treatment at the lowest dose; implementing a surveillance plan; being willing to revisit previous drug and non-drug treatments that have failed; reinforcing positive prescription outcomes; involving family members; and utilizing a multidisciplinary team approach.

“Involve and engage family members and paid caregivers and seek out other resources that can help to reinforce adherence to treatment and maintain gains from treatment,” Dr. Reid advised. “Consider specialist referral for older patients who have complicated psychiatric histories, debilitating pain, or pain that does not respond to customary treatments.”

References

1. Helme RD, Gibson SJ. The epidemiology of pain in elderly people.  Clin Geriatr Med. 2001;17(3):417-431.

2. Marcum ZA, Hanlon JT. Commentary on the new American Geriatric Society beers criteria for potentially inappropriate medication use in older adults. Am J Geriatric Pharmacol. 2012;10(2):151-159.

3. Wilcox CM, Cryer B, Triadafilopoulos G. Patterns of use and public perception of over-the-counter pain relievers: focus on nonsteroidal anti-inflammatory drugs. J Rheumatol. 2005;32:2218-2224.

3. Campbell C, Weisner C, LeResche L, et al. Age and gender trends in long-term opioid analgesic use for noncancer pain. Am J Pub Health. 2010;100:2541-2547.

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