Chronic pain affects between 20–50 per cent of elderly people and is often multi-factorial and complex. Such pains are mostly unrecognised, treated sub-optimally or not treated at all. This may be related to attitudes and beliefs held by older people, which in turn affects their reporting of pain but also due to misconceptions and educational deficits by health professionals. There is also a general failure by professionals to consider alternative pain relief options. Pain may significantly reduce quality of life and lead to depression, anxiety, increased suicide risk, increased dependence, reduced appetite, impaired gait, sleep disturbances and other problems.
Pain problems common in the geriatric age group include joint pains (e.g. osteoarthritis, rheumatoid arthritis), low back pain (facet syndrome or degenerative disc disease), cancer pain, angina, neuropathic pains (diabetic neuropathy, post-herpetic neuropathy/ shingles), trigeminal neuralgia, peripheral vascular disease and ischemic pain. Osteoporosis is another common contributor to chronic back pain in elderly, especially in females.
| Dr Pushpinder Singh |
A pain management clinic in a hospital can help to reduce the sufferings of such elderly people and improve their quality of life. Apart from pharmacologic management, pain management clinics do offer interventional pain procedures for various pain conditions along with psychological support, physical activity and assistive devices and other complementary therapies.
The complexity of pain assessment in geriatric patients often requires a multidisciplinary approach to diagnosis and management. The pain physician needs to work together with a psychologist or psychiatrist as depression is often times present in the patient with chronic pain. A physical therapist is a part of the team as well, to help with functionality. Laboratory and imaging studies may be ordered to help pinpoint a diagnosis if a detailed history and physical examination is not enough.
Evaluation of the patient’s level of function is important as it affects the degree of independence, level of need for caregivers, as well as overall quality of life. Activities of daily living (ADL)—eating, bathing, dressing—and instrumental ADLs—light housework, shopping, managing money, preparing meals—are assessed. After a diagnosis is made, a consensus treatment plan is outlined that includes modalities to decrease pain perception and increase patient function.
| Pain management modalities in the elderly |
| Pharmacotherapy
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A solid support system including relatives and caregivers should be established |
Interventional pain modalities often alleviate the need for heavy medications use, thereby sparing the patient from unwanted side effects |
Physical activity and assistive devices encompass a wide range of interventions |
Pain management modalities in the elderly
Older people are different; the bio-physiological changes that occur with ageing, the accumulation of co-morbidities and co-prescription of medication, frailty and psychosocial changes make older people rather unique when considering treatment modalities for pain control.
Treatment modalities in a pain management clinic may be categorised into the following areas:
Pharmacotherapy
Drug treatment is generally the first and most widely used treatment modality to control geriatric pain. It is relatively simple to implement and consists of NSAIDs, muscle relaxants, opioids especially in cancer pain and other adjuvant therapy. While paracetamol is most commonly used drug because of its safety profile in elderly, other NSAIDs and COX 2 inhibitors are resorted to for non responsive pain and opioids like morphine reserved for moderate to severe pain especially cancer pain. Long-term treatment with NSAIDs can cause gastric bleeding, deranged kidney functions and thus should be avoided. Adjuvant drug therapy such as antidepressants, anticonvulsants, muscle relaxants etc. are considered at all times to enhance the analgesic effects of other medications.
Interventional pain procedures
Interventional therapies in the management of chronic pain are minimally invasive procedures, mostly done as day care under image guidance in operation theatre with minimal morbidity. Interventional pain modalities often alleviate the need for heavy medications use, thereby sparing the patient from unwanted side effects associated with larger doses of drugs. Nerve blocks are some of the most commonly used interventional procedures employed by pain physicians, these help not only with diagnosis but also prognosis, pre-emptive analgesia, and sometimes definitive therapy. Other interventions that may be used include chemical neurolysis, radio-frequency lesioning, cryoneurolysis, neuroaugmentation and neuraxial drug delivery. Depending upon the clinical diagnosis various interventions can be offered to the patients.
Knee osteoarthritis is a common condition in old age and is responsible for reduced quality of life. In early stages, intra-articular hyaluronic acid is effective and appears to have a slower onset of action but lasts longer than steroids. Radio-frequency of genicular nerves has a strong scientific evidence to provide long lasting reduction in pain especially in late stages of osteoarthritis and helps in improving functionality.
Chronic low back pain in elderly is mostly due to facet arthropathy or degenerative disc disease. While medial branch block and subsequent radio-frequency lesioning carry strong evidence in scientific literature, epidural steroid injections by transforaminal or caudal route are undertaken for lumbar canal stenosis. The treatment for degenerative disc disease includes percutaneous intradiscal RF therapy and Rami communicans lesioning which has good scientific evidence. Painful vertebral fractures respond well to percutaneous vertebroplasty and kyphoplasty.
Neuropathic pains such as sciatica, post herpetic neuralgia do respond to specific nerve blocks and steroid injection. Trigeminal neuralgia responds excellently to radiofrequency lesioning of trigeminal ganglion and percutaneous balloon compression.
Interventional pain procedures thus should be considered in management of chronic pain especially when pharmacological treatments are ineffective or not tolerated.
Psychological support
Because pain is a complex sensory and emotional experience, psychological modalities should be employed in the pain management model. Pain coping strategies may include relaxation, prayer and attention diversion techniques. Depression and anxiety in geriatric patient must be addressed with psychotherapy, meditation and medication. Socio-economic variables of each patient should be adjusted to help the patient cope with pain. A solid support system including relatives and caregivers should be established.
Physical activity and assistive devices
Physical activity and assistive devices encompass a wide range of interventions. The available evidence supports the use of programmes that comprise strengthening, flexibility and endurance activities to increase physical activity, improve function and pain.
The assistive devices are designed to assist in activities of daily living. Scientific evidence suggests that assistive devices may support community living, reduce functional decline, reduce care costs and reduce pain intensity relative to older people not provided with devices.
Apart from these, some types of complementary therapy [e.g. acupuncture, transcutaneous electrical nerve stimulation (TENS), massage] have been used for older adults with painful conditions.
To summarise, chronic or persistent pain is not an inevitable part of ageing but is fairly common among the elderly. The treatment of pain may be complicated by multiple problems that are far less likely to occur in younger adults. Understanding the causes of this pain, special medical needs of the elderly and the role of pain self- management can help seniors to reduce or eliminate this condition. Pain management clinics can provide appropriate analgesia in geriatric patients through proper assessment, a multidisciplinary approach and appropriate use of treatment modalities.