Chronic Pain Management in the Elderly

Abstract

Chronic pain is extremely prevalent in older adults and is associated with significant morbidity, including limited mobility, social isolation, and depressed mood. Pain is defined by a biopsychosocial model highlighting the importance of a multidisciplinary approach to treatment, including multimodal medications, selected interventions, physical therapy and rehabilitation, and psychological treatments. In this narrative review, the authors highlight the use of these approaches in older adults with specific attention paid to considerations unique to aging, including alterations in drug metabolism, avoidance of polypharmacy, and physiologic changes predisposing to painful conditions.

Keywords: Chronic pain; Multidisciplinary treatment; Opioids; Polypharmacy.

Figure 1.. Breaking the Cycles of Pain.

Pain is a complex biopsychosocial disease that can affect all aspects of life including mood, sleep, cognition and function. This is particularly difficult for older adults who may already have co-morbid conditions contributing to problems in these areas or who may undergo surgeries that increase their risk of chronic pain. Using a multidisciplinary approach to treat chronic pain is the most likely to be effective and treatment plans should include multimodal medication options, physical therapy, pain psychology and selected interventions, as appropriate. Courtesy of M.C. Kao, PhD, MD, CIPS, FIPP, Palo Alto, CA.

Figure 2.. Sites of action of multidisciplinary treatments for pain management.

In most cases pain is initiated in the periphery where primary afferent neuron terminals may be activated by local inflammatory mediators. Transduction of this signal from the peripheral to the central nervous system can be blocked by certain categories of drugs (NSAIDs, opioids, local anesthetics) and by increasing strength and mobility through physical therapy. Painful signals are then transmitted to the dorsal horn of the spinal cord where the central terminals of the primary afferent neurons form synapses with intrinsic spinal cord neurons. Gabapentinoids, opioids, local anesthetics and certain interventions can block this peripheral-to-central transmission. Finally, the painful signal is carried to the brain through ascending pathways for perception to occur and descending pathways can also be activated to modulate inputs in the spinal cord. Many medications can act on these systems including serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), N-methyl-D-aspartate (NMDA) receptor antagonists and opioids. Importantly, psychological interventions can engage descending inhibitory pathways to suppress painful signal transmission. Using multidisciplinary approaches that target different areas of the peripheral and central nervous system may limit side effects and improve efficacy of treatments.