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Review
. 2014 Aug 27;312(8):825-36.
doi: 10.1001/jama.2014.9405.

Management of persistent pain in the older patient: a clinical review

Una E Makris  1 , Robert C Abrams  2 , Barry Gurland  3 , M Carrington Reid  4
Affiliations
Review

Management of persistent pain in the older patient: a clinical review

Una E Makris et al. JAMA. .

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.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Reid reported serving as a consultant to Endo Pharmaceuticals. No other authors reported disclosures.

Figures

Figure 1
Figure 1. Treatment Algorithms for Nociceptive and Neuropathic Pain Disorders in Older Adults
Figure 2
Figure 2. Approach for Monitoring Pain Management and Adjusting Medication for Older Adults Already Taking Analgesic Medications
See this image and copyright information in PMC

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