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The American Journal of Medicine (2007) 120, 306-315

PDATE IN OFFICE MANAGEMENT

ffice Management of Chronic Pain in the Elderlyebra K. Weiner, MDivision of Geriatric Medicine, Department of Medicine, Department of Psychiatry, and Department of Anesthesiology,
niversity of Pit
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E-mail address

002-9343/$ -see foi:10.1016/j.amjm

tsburgh, Pittsburgh, Penn.

ABSTRACT

hronic pain plagues older adults more than any other age group; thus, practitioners must be able topproach this problem with confidence and skill. This article reviews the assessment and treatment of theost common chronic nonmalignant pain conditions that affect older adults—myofascial pain, generalized

steoarthritis, chronic low back pain (CLBP), fibromyalgia syndrome, and peripheral neuropathy. Specificopics include essential components of the physical examination; how and when to use basic and advancedmaging in older adults with CLBP; a stepped care approach to treating older adults with generalizedsteoarthritis and CLBP, including noninvasive and invasive management techniques; how to diagnosend treat myofascial pain; strategies to identify the older adult with fibromyalgia syndrome and avoidnnecessary “diagnostic” testing; pharmacological treatment for the older adult with peripheral neuropa-hy; identification and treatment of other factors such as dementia and depression that may significantlynfluence response to pain treatment; and when to refer the patient to a pain specialist. While common,hronic pain is not a normal part of aging, and it should be treated with an emphasis on improved physicalunction and quality of life. © 2007 Elsevier Inc. All rights reserved.

KEYWORDS: Chronic pain; Elderly; Evaluation; Treatment; Low back pain; Fibromyalgia; Syndrome; Myofascialpain; Peripheral neuropathy; Generalized osteoarthritis

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hronic pain is a treatable problem affecting an estimated0% of community-dwelling older adults and over 75% ofong-term care facility residents. Because of its numerousonsequences, including impaired physical function, de-ression, anxiety, disrupted sleep and appetite, and exces-ive use of health care resources, chronic pain should bereated aggressively. Chronic pain may accompany bothalignant and nonmalignant disorders. This article focuses

n the evaluation and management of chronic nonmalignantain.

EFINITION AND PATHOGENESIS OF CHRONICONMALIGNANT PAINhronic pain is defined as pain that persists beyond thexpected time of healing, or more than 3 to 6 months. Whilenumber of disorders may cause chronic pain, generally

Requests for reprints should be addressed to Debra K. Weiner, MD,PMC Pain Medicine at Centre Commons, 5750 Centre Ave., Suite 400,ittsburgh, PA 15206.

t: [email protected]

ront matter © 2007 Elsevier Inc. All rights reserved.ed.2006.05.048

peaking there are 2 types of conditions that underlie itsathogenesis—nociceptive and neuropathic. The nervousystem is responsible for the perception of pain. Nociceptiveain is associated with tissue damage and a normal nervousystem (eg, pain associated with osteoarthritis), while neu-opathic pain is associated with physiological nervous sys-em dysfunction (eg, diabetic neuropathy, postherpetic neu-algia). Not infrequently, these 2 types of pain coexist. Theiscussion that follows focuses on the most commonhronic nonmalignant pain disorders—myofascial pain, os-eoarthritis, chronic low back pain, fibromyalgia syndrome,nd peripheral neuropathy.

ENERAL APPROACH TO ASSESSMENTND TREATMENTo afford an optimal response to therapy, the practitionerust keep 3 general principles in mind, and communicate

hem to their older patients in order to establish reasonable
reatment expectations:

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307Weiner Chronic Pain in the Elderly

Chronic pain is a syndrome with many potential contrib-utors, all of which require treatment to afford an optimalclinical outcome.Chronic pain is treatable but not curable; improvement isthe rule, not the exception.It is often possible to improve functional ability to agreater extent than the severity of pain is reduced.

VALUATION AND TREATMENT OF SPECIFICHRONICAIN DISORDERS

yofascial Painefinition and Pathogenesis. Because myofascial pain

MP) occurs in the majority of patients with chronic painisorders, learning how to recognize, diagnose, and treathis condition is essential. Broadly defined, myofascial pains pain in physiologically abnormal muscles. The pathogno-onic features of this disorder are taut bands and trigger

oints elicited by firm palpation.1 Patients may present withrange of pain symptoms such as aching, soreness, stab-

ing, or burning. The descriptors used by patients sufferingrom myofascial pain may be similar to those of neuropathicain, and sometimes these disorders occur together; thus,ands-on assessment is critical to accurate diagnosis. Myo-ascial pain is commonly associated with degenerativehanges of the axial skeleton and other factors (eg, spinaleformity, such as scoliosis or kyphosis) that may irritateerves. As a result, the musculature supplied by theseerves does not receive adequate trophic factors and it, inurn, becomes irritable.2

valuation. Careful physical examination is required toiagnose myofascial pain. Historical clues include: relief ofain by exerting mild pressure over the area (eg, massaginghe affected area), engaging in low level activity, or appli-ation of heat or vapocoolant spray; and worsening of painith excessive activity. Physical examination performed byrmly palpating involved muscles may reveal both latentnd active trigger points.1 Palpation of latent trigger pointsay cause tenderness, but may not reproduce the radiation

f pain that occurs when active trigger points are palpated.aut bands can be identified by firmly palpating the musclelong the same plane but in the axis that runs perpendicularo the direction of the muscle fibers. The examiner may needo apply pressure in this area for 10-15 seconds before theharacteristic pain pattern is reproduced.3 Local twitch re-ponses, due to sharp contractions of the taut band (not thentire muscle) initiated by an intense physical stimulus suchs needle insertion or plucking of the band may also beoted.1 Sensory abnormalities include hypersensitivity andllodynia (ie, pain caused by a stimulus that does not nor-ally provoke pain) of the trigger points. Autonomic phe-

omena, such as temperature change, piloerection, andweating, may be present in the affected area but are not
equired for diagnosis. a
reatment. The first step in the treatment of MP is identi-cation and modification of perpetuating factors, such asosture, sleeping position, and body mechanics during ac-ivity. Early involvement of a physical therapist skilled inhe treatment of myofascial pain disorders is crucial. Phys-cal therapy techniques commonly employed include gentleustained stretching of involved muscles to reduce focalontractions and inactivate trigger points, sometimes inombination with a vapocoolant spray; exercise programshat include graded stretching and strengthening; and teach-ng of flare self-management techniques.4 In order to facil-tate physical therapy-directed rehabilitation, trigger pointeactivation may be useful. This can be accomplished withither “dry needling” (ie, deactivating the trigger point withneedle alone) or injection of the trigger point with an

nesthetic or steroid. Either technique may be effective asong as a local twitch response (ie, transient contraction of

group of tense muscle fibers [taut band] that traverse arigger point) is achieved.5 This author also has had successith a variety of acupuncture techniques. In refractory

ases, referral to a multidisciplinary pain center may beelpful.

steoarthritis and Chronic Low Back Painefinition and Pathogenesis. Osteoarthritis (OA) is com-only referred to as degenerative arthritis, but this is some-hat of a misnomer. Accumulating evidence indicates that

nflammation plays an important role in the pathogenesis ofA. While virtually all older adults have radiographic evi-ence of OA, most of these individuals are asymptomatic,nd the severity of OA on radiograph correlates poorly withymptom severity. In the case of chronic low back painCLBP), degenerative disease of the discs and facets is onlyne factor that contributes to pain; thus, its evaluation andreatment should be approached comprehensively.

valuation. Proper treatment of appendicular OA (eg,nees, hips) and CLBP requires a detailed evaluation. Sev-ral rheumatologic disorders can cause generalized pain anday be confused with OA. Table 1 summarizes clinical

eatures of common rheumatologic conditions.The first step in evaluating low back pain is the identi-

cation of “red flags” (eg, fever, unintentional weight loss,udden change in pain quality) indicative of a serious un-erlying disorder such as malignancy or spinal infectionFigure 1). These should be screened with a targeted historynd physical examination. If a serious condition is sus-ected, diagnostic imaging should be pursued promptly.onversely, in the absence of red flags, imaging is rarely

ndicated.6 Practitioners receive little training in musculo-keletal assessment, thus, basic and advanced imaging (ie,adiographs and magnetic resonance imaging [MRI]/com-uterized tomography [CT], respectively) is often reliedpon as an initial diagnostic test. This approach, however, isikely to lead to incorrect management because degenerative
bnormalities are a nonspecific finding in older adults with

Table 1 Differentiation of Osteoarthritis from other Common Rheumatologic Disorders: History, Physical Examination and Other Diagnostic Features

Disorder

History Physical ExaminationOther DiagnosticFeatures/CommentsAM Stiffness Location of Pain Synovitis Extrasynovial Disease

Osteoarthritis Generally short-lived,eg, �30 minutes

Weight-bearing appendicular joints,cervical and lumbar spine, DIPs,PIPs and 1st CMC. MCP and wristinvolvement go against OA.

Absent or mild None related to arthritis itself Because OA is ubiquitous in olderadults, radiographs should be used torule out other disorders, not todiagnose OA.

Pseudogout Pseudo-rheumatoidpattern may beassociated withprolonged AMstiffness

Knee and wrist are most commonlocations; disease is oftensymmetrical

Acute flares are intenselyinflammatory

Chondrocalcinosis onradiographs; eye deposits,bursitis, tendonitis, carpaland cubital tunnel syndromesmay occur. Tophaceous softtissue deposits uncommon.

Chondrocalcinosis may beasymptomatic. Identification ofintracellular CPPD crystalsoffers a definitive diagnosis in acuteflares. Acute and chronic forms occur.

Gout Pseudo-rheumatoidpattern may beassociated withprolonged AMstiffness

Joints of the lower extremities aremost often involved, especially 1st

MTP; disease is typicallyasymmetrical

Acute flares are intenselyinflammatory

Tophi may deposit in softtissues.

Hyperuricemia may be asymptomatic.Serum uric acid cannot diagnose gout.Identification of intracellularmonosodium urate monohydratecrystals offers a definitive diagnosis inacute flares.

RheumatoidArthritis

Prolonged, eg, �30minutes. Durationof stiffness is usedas one parameterof disease activity

Any synovial joint. The lumbarspine is typically spared.

Present. Not uncommon; rheumatoidnodules can develop in softtissues. Many other possiblemanifestations includinganemia, vasculitis (skinlesions, peripheralneuropathy, pericarditis,visceral arteritis, palpablepurpura), pulmonary disease,etc.

Patients may be seronegative. Ifdisease is suspected, patient shouldpromptly be referred to arheumatologist to retard diseaseprogression.

Systemic LupusErythematosus

Not a prominentfeature.

Depends upon tissues involved—may or may not be limited tojoints. Comorbid fibromyalgia is notuncommon.

Generally absent; arthralgiasare more common thanarthritis.

Common—eg, anemia, skinrash, pleuritis, peritonitis,pericarditis, nephritis,meningitis, etc.

Anyone with suspected SLE shouldpromptly be referred to arheumatologist.

FibromyalgiaSyndrome

Generally short-lived,eg, �30 minutes

Typically diffuse. Worst symptomsoften involve the axial skeleton.

Absent. Joints themselvesare not involved, althoughpatients experience pain injoints and soft tissues.

Many other disorders maycoexist (Table 4)

Fibromyalgia syndrome is not adiagnosis of exclusion, but one basedupon careful history and physicalexamination(see text).

PolymyalgiaRheumatica

May be prolonged,lasting severalhours

Typically proximal—eg, shouldergirdle, hip girdle, neck. Ifheadaches, jaw claudication, orprominent systemic symptoms (eg,fever), consider temporal arteritis.

May occur, especially insmall joints of hands.

Occurs if comorbid temporalarteritis and relates toinvolvement of arteries (eg,Raynaud’s phenomenon,bruits, claudication).

Because the erythrocyte sedimentationis very nonspecific, this test should beused to assist with confirmation of asuspected diagnosis. Note that casesof PMR and TA with a normal ESR havebeen reported.

CMC � carpo-metacarpal joint; CPPD � calcium pyrophosphate dihydrate; DIP � distal interphalangeal joint; ESR � erythrocyte sedimentation rate; MCP � metacarpophalangeal joint;MTP � metatarsophalangeal joint; OA � osteoarthritis; PIP � proximal interphalangeal joint; PMR � polymyalgia rheumatica; SLE � systemic lupus erythematosus; TA � temporal arteritis.

308The

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ack pain. Indeed, virtually 100% of older adults haveegenerative pathology, whether or not they have pain.hen used as a screening tool, imaging should be thought

f as a way to demonstrate the absence of disease (eg,

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YES

Symptoms Severeand/or associated withrecent neurological deficits?

YES

Advanced Imaging+

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NO

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Analgesics

Figure 1 Evaluation and treatment of

Table 2 Essential Clinical History Questions for Older Adults w

Question Potential Dia

1. Can you show me where your back hurts? If patient plspine, this sor knee diseinsufficiency

2. Does the pain get better or worse whenyou curl up in bed?

Improvemenposition sugposition.

3. Does the pain go into your buttocks?If “yes”: Is the pain sharp or dull?

Buttocks invpain (often sevaluation.

4. Do you have pain in your groin? Groin pain cpathology, s

5. Does the pain shoot down your leg(s)?If “yes”: In what part of your leg do youfeel the pain? Is the pain sharp or dull?

Posterior radLateral thighthe knee) orLateral leg pAnterior thigstrain with k

6. Is the pain made better or worse withwalking?

Worsening wImprovemenProlonged wassociated wexcessive us

7. Do you sometimes feel that you have painall over?

Patients withpresent withis just one o

Reprinted from: Weiner DK, Cayea D. Low back pain and its contributin Older Persons, Progress in Pain Research and Management, Vol. 35. SeatIASP Press.

ompression fractures, metastatic bone disease, disk spacenfection) rather than as a way to diagnose the cause of pain.

Moderate to severe central spinal canal stenosis identi-ed by MRI is also as common in older adults with pain as

ient History

Red Flags?

Comprehensive Physical Examinationof the Low Back and Legs

algia

ogy or

Sacroiliac pain,Myofascial pain

Physical Therapy

NO

ProminentHip Disease

Orthopedist

Adjunctive Modalities and Medications

nosis?

NO

Basic or AdvancedImaging;

Treat per findingsYES

er adult with persistent low back pain.

ronic Low Back Pain

c Clue(s) Obtained

nd to right or left of midline, over sacrum rather than lumbars sacroiliac joint syndrome (look for associated scoliosis, hipg length discrepancy), inflammatory disorder, or sacralre.al position suggests spinal stenosis. Worsening in fetalacroiliac disease because of joint compression in this

nt can be associated with hip disease, piriformis myofascialr burning), or spinal stenosis and requires contextual

ssociated with intrinsic hip disease, local myofascialc joint syndrome, or an insufficiency fracture.is consistent with sciatica (sharp) or spinal stenosis (dull).ion suggests tensor fascia lata/iliotibial band pain (not pasts minimus (past the knee “pseudo-sciatica”) myofascial pain.

th paresthesias or numbness suggests L5 radiculopathy.suggests hip disease, meralgia paresthetica, quadriceps

teoarthritis, or L2/3/4 radiculopathy.lking suggests spinal stenosis or vasogenic claudication.walking suggests myofascial pathology or neuropathic pain.may worsen myofascial pain. Degenerative disease may betial pain/stiffness, then improvement and worsening with

yalgia syndrome often have prominent axial pain, and mayf complaint of severe low back pain, but in fact low back painsites of pain.

lder adults: a practical approach to evaluation and treatment. In: Painshington: IASP Press; 2005:332, with permission from Debra Weiner and

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310 The American Journal of Medicine, Vol 120, No 4, April 2007

Table 3 Physical Examination Abnormalities in Older Adults with Low Back Pain

Finding Operational Definition Examination Technique

Fibromyalgia tenderpoints

Presence of pain whenapproximately 4 kgof force is appliedto defined tenderpoints.

Have patient sit comfortably on examination table, arms resting in lap.Tell patient that you are going to apply pressure at several points on the body, and that

you want to know if pressure on any point causes pain.Examine the following points bilaterally, using enough pressure to blanch thumb nail:(1) Occiput at suboccipital muscle insertions(2) Low cervical at the anterior aspects of the intertransverse spaces at C5-C7(3) Trapezius, midpoint of upper border(4) Supraspinatus at origins, above the scapular spine near the medial border(5) 2nd rib at the 2nd costochondral junction, just lateral to the junction on the upper

surfaces(6) Lateral epicondyle 2 cm distal to the epicondyle(7) Medial fat pad of the knee, proximal to joint line(8) Greater trochanter, just posterior to the trochanteric prominence(9) Gluteal at upper outer quadrant of buttocks in anterior fold of muscle

Functional leglengthdiscrepancy

Pelvic asymmetry Have patient stand with both feet on floor, shoes removed. Ask him to stand with feettogether, and as erect as possible.

Kneel behind patient. With palms parallel to floor, and fingers extended, place lateralsurface of index finger of both hands atop pelvic brim bilaterally. Eyes should be levelwith hands.

Determine if right and left thumbs are at different heights.Scoliosis (lateral/

rotational)Lateral/rotational

curvature ofthoracolumbar spine

Have patient stand on floor with shoes removed. Stand behind patient. Run index fingeralong spinous processes (do not lift hand between vertebrae) a series of 3 times. If youdo not detect scoliosis, then:

Ask patient to bend forward. Determine if there is asymmetry in height of paraspinalmusculature.

Sacroiliac jointpain

Pain with directpalpation ofsacroiliac joint orwith Patrick’s test

Direct Palpation: Have patient stand on floor with shoes removed. Stand behind patient.Exert firm pressure over sacroiliac joint, first on one side, then the other. Palpate rightjoint with right thumb, standing to left side of patient; palpate left joint with leftthumb, standing to right of patient.

Patrick’s (FABER) Test—Have the patient lie supine on the examining table and place thefoot of involved side on opposite knee. Then slowly lower the test leg in abductiontoward the examining table. If patient reports pain in back (not groin, buttocks or leg),then test is positive.

Myofascial pain,piriformis

Presence of pain ondeep palpation ofpiriformis.

Have patient lay supine on examination table.Have patient flex right hip and knee, keeping sole of foot on table.Cross bent leg over opposite leg; again place sole on table and exert mild medially

directed pressure on lateral aspect of knee to put piriformis in stretch.Exert firm pressure (4 kg) over middle extent of piriformis.Repeat examination on opposite side.

Myofascial pain,tensor fascia lata(TFL) � iliotibial(IT) band pain

Presence of pain ondeep palpation ofTFL or IT band.

Have patient lying supine on examination table. Using thumbs of both hands, exert firmpressure (4 kg) over full extent of TFL and IT band.

Repeat examination on opposite side.

Kyphosis Deformity of thoracicspine creatingforward flexedposture

Have patient stand on floor with shoes removed. Ask him to stand fully erect.Inspect posture from the side.

Myofascial pain ofparalumbarmusculature

Presence of pain ondeep palpation ofparalumbarmusculature.

Have patient stand on floor with shoes removed. Stand behind and to left of patient andbrace patient in front with left arm. Palpate full extent of right paravertebral musculaturewith right thumb. Exert approximately 4 kg force. Repeat, palpating the left paravertebralmusculature.

Vertebral body pain Presence of pain onfirm palpation oflumbar spinousprocesses

Position yourself behind patient, as for examination of paravertebral musculature above.Using dominant thumb, firmly palpate spinous processes L1-L5.

Hip disease Pain and restrictedmotion of hip

Hip Internal Rotation—Have patient lie supine on examining table with hip and knee bentto 90°. Put the hip into maximum internal rotation (should be �15°) and ask patient if heexperiences pain.

Patrick’s Test—As above, but pain may be in groin or leg.

Modified and reprinted from: Weiner DK, Sakamoto S, Perera S, Breuer P. Chronic low back pain in older adults: prevalence, reliability, and validityof physical examination findings. J Am Geriatr Soc. 2006;54:11-20; with permission from Debra Weiner and Blackwell Publishing.

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n those without pain.7 In part for this reason, failed backurgery syndrome occurs in up to 40% of patients whenreatment decisions are based on the results of advancedmaging alone. Factors that increase the risk of failed backurgery syndrome include scoliosis, hip disease, and osteo-orotic compression fractures, all of which are common inlder adults.8,9 Because these factors can alter gait or spinaliomechanics, their close relationship with low back pain isot surprising.

Essential elements of the history and physical examina-ion for the older adult with CLBP are shown in Tables 2nd 3. Because low back pain is a syndrome, typically morehan one abnormality will be uncovered.

reatment. Treatment of appendicular OA and CLBPhould be directed toward each of its individual contribu-ors. In addition to treating the physical causes, carefulttention should be paid to the many psychosocial factorshat can impact pain and function, such as anxiety, depres-ion, and fear. A stepped care approach to the treatment ofppendicular OA and CLBP is shown in Figure 2. Note onhe right side of Figure 2, “topical preparations, cognitive-ehavioral therapy, interdisciplinary pain treatment, andomplementary and alternative modalities (CAM).” Thesereatments should be considered alone or in combinationith any of the individual step components described be-

ow. Discussion of CAM is beyond the scope of this article.nterested readers are referred to a recent review of CAMor chronic pain in older adults.10

Step 1 includes patient education, exercise,11 weight loss,nd prescription of assistive devices (eg, canes, walkers).

Step 2 focuses on injection therapies. Even though injec-ions are invasive, the risk of these procedures when per-ormed by experienced clinicians is less than that of sys-emic analgesics. Injections should be considered for thelder adult with pain in 1 or 2 joints, eg, bilateral kneesteoarthritis. The value of corticosteroid injections for theatient with CLBP is less clear. The strongest evidence forffectiveness is in the setting of a herniated disk associatedith radiculopathy. A critical review of minimally invasiverocedures for the patient with low back pain is provided

Education, Exercise, Weight Loss, Assistive Devices

Injections

Acetaminophen

Non-acetylated salicylates

Strong Opioids

Surgery

Topical Preparations,Cognitive Behavioral Therapy,Interdisciplinary Pain Therapy,

CAM Modalities

Other NSAIDs, Weak Opioids

igure 2 Stepped care approach to the treatment of axial andppendicular osteoarthritis.

lsewhere.12 In general, injection therapies should be

iewed as a tool to enhance compliance with rehabilitationfforts, which represent the mainstay of CLBP and gener-lized OA treatment.

Steps 3 through 6 include a range of pharmacologicptions. If regularly scheduled acetaminophen fails, nonac-tylated salicylates (eg, salsalate, choline magnesium trisa-icylate) should be considered because of their superioride-effect profile as compared with traditional nonsteroidalnti-inflammatory drugs (NSAIDs). Medications in Step 5other NSAIDs and weak opioids) include propoxyphene,odeine, hydrocodone, and tramadol. Propoxyphene is gen-rally contraindicated in older adults because it is no moreffective than placebo and retains many of the toxicities ofore potent and effective opioids. Codeine is an effective

ntitussive but a weak analgesic. Before prescribing eithereak or strong opioids, patients must be counseled about

heir potential side effects, and those that are preventablehould be addressed. For example, opioids increase the riskf falls; therefore, physical therapy to enhance the patient’sobility and stability is recommended before opioids are

rescribed. In addition, a stimulant laxative (eg, senna)hould be taken at the first sign of constipation. Detailedecommendations regarding dosing of nonopioid and opioidnalgesics, precautions, and potential drug-drug interactionsave been published by the American Geriatrics Society.13

Step 7 includes surgical procedures. In general, total jointeplacement is considered after noninvasive or minimallynvasive strategies have failed to control pain. Guidelinesegarding when to pursue surgical treatment for refractoryow back pain are less clear. Back surgery is elective in theast majority of cases and rates of failed back surgeryyndrome are substantial, with estimates ranging from 5%

Table 4 Symptoms and Disorders that Commonly Coexist inPatients with Fibromyalgia Syndrome

Postexertional painRestless legsSleep apneaAnxiety and depressionDysesthesias and paresthesiasImpaired memory and concentrationVague auditory, vestibular, and ocular symptomsIntolerance or allergies to multiple medicationsPalpitationsDyspneaRegional pain syndromes● Tension and migraine headaches● Atypical chest pain● Temporomandibular symptoms● Myofascial pain● Pelvic pain● DyspareuniaIrritable bowel syndromeCold intoleranceUrinary frequency with interstitial cystitisSubjective joint swellingFluid retentionUnexplained bruising

Table 5 First-line Medications for Neuropathic Pain

Medication Class Medication Pharmacokinetics Key Drug-Drug InteractionsKey Drug-DiseaseInteractions Important Adverse Effects

TricyclicAntidepressants(TCAs)

NortriptylineDesipramine(Amitriptyline)

Hepatic metabolism;higher levels ofactive metabolitesin the elderly

Antipsychotics, anticholinergics,selective serotonin reuptakeinhibitors (SSRI), sedative-hypnotics, antiarrhythmics,MAO inhibitors, clonidine,antiretrovirals

Myocardial infarction, QTprolongation, AVblock, bundle branchblock, ileus, prostatichypertrophy,glaucoma, seizuredisorder, dementia

Arrhythmia, cardiac conduction block,orthostatic hypotension, urinaryretention, constipation, cognitiveimpairment; adverse withdrawalevents after abruptdiscontinuation; death if torsadesde pointes

Anticonvulsants Gabapentin Renal elimination;prolonged half-life with renalimpairment

Opioids Dementia, ataxia Somnolence, dizziness, peripheraledema, increased appetite andweight gain, adverse withdrawalevents after abrupt discontinuation

Opioids andopioid-likedrugs

OxycodoneMorphineTramadol

Hepatic metabolismand renalelimination;plasma levels maybe higher in theelderly

Anticholinergics, sedative-hypnotics, anxiolytics, CYP2D6inhibitors, SSRIs, TCAs,muscle relaxants

Ileus, chronicobstructive pulmonarydisease, dementia,prostatic hypertrophy

Constipation, sedation,nausea/vomiting, respiratorydepression, nervous systemsymptoms, pruritis, adversewithdrawal events after abruptdiscontinuation

Topicalanesthetics

Topical lidocainepatch 5%

Very little systemicabsorption

Class I antiarrhythmics Skin rash

Reprinted from: Schmader KE, Dworkin RH. Clinical features and treatment of postherpetic neuralgia and peripheral neuropathy in older adults. In: Gibson SJ, Weiner DK, eds. Pain in Older Persons, Progressin Pain Research and Management, Vol. 35. Seattle, Washington: IASP Press; 2005:363, with permission from IASP Press.

312The

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o 40%. Thus, back surgery should be considered for clear-ut cases, such as deterioration of neurological function orherniated disc with anatomical location correlating pre-

isely with symptom location and failure to respond toonsurgical management. Otherwise, back surgery shoulde considered cautiously. The value of minimally invasiveurgical procedures for the treatment of low back pain isurrently under investigation.

ibromyalgia Syndromeefinition and Pathogenesis. Fibromyalgia syndrome

FMS) affects 7% of women between the ages of 60 and 79ears.14 FMS is characterized by generalized pain and char-cteristic tender points on physical examination (Table 3).ost patients with FMS also suffer from morning stiffness,

atigue, and nonrestorative sleep. Once thought of as anllness based in psychopathology, it is now recognized thatMS is associated with dysregulation of the central nervousystem. That is, the nervous system of the FMS patient doesot process pain normally.

valuation. A careful history and physical examination ishe key to FMS diagnosis. It is not a diagnosis of exclusion.

number of other disorders may coexist in patients with

Table 6 Dosage of First-Line Medications for Neuropathic Pai

Medication Beginning Dosage Titration

Gabapentin 100-300 mg qhs Increase by 100a day every 1-7tolerated in divdoses up to tid

Lidocaine patch5%

Maximum of 3patches daily for amaximum of 12hours

None needed

Opioidanalgesics(dosagesgiven are formorphine)

2.5-15 mg every 4hours as needed

After 1-2 weekstotal daily dosalong-acting opianalgesic and cshort-acting meas needed

Tramadol 25 mg once daily Increase by 25-daily in dividedevery 3-7 daystolerated

Tricyclicantidepressants,especiallynortriptylineordesipramine

10-25 mg qhs Increase by 10-daily every 3-7tolerated

Reprinted from: Schmader KE, Dworkin RH. Clinical features and treIn: Gibson SJ, Weiner DK, eds. Pain in Older Persons, Progress in Pain Resepermission from IASP Press. Originally adapted with permission from: Dwo

MS, such as migraine headaches, depression, and sleep r

pnea. Table 4 lists these disorders as well as other symp-oms from which patients with FMS suffer. Often, patientseport pain for decades, even during childhood (eg, “growingains”). There is increasing evidence that FMS is a heritableisorder, thus practitioners should obtain a thorough familyistory in the older adult with suspected FMS.

A combination of characteristic symptoms along withalpation-elicited tenderness supports a diagnosis of FMS.he presence of �11 of 18 characteristic tender points haseen used for classification purposes (ie, distinguishing pa-ients with FMS from those with other rheumatologic dis-rders), but this exact number is not required to make aiagnosis. Typically, patients with FMS have widespreadenderness (ie, pain elicited by palpation when the examinerses enough pressure to blanch the thumbnail bed).

reatment. Aerobic exercise is an important component ofreatment. The symptoms that most interfere with patients’uality of life include pain, fatigue, limited activity toler-nce, and sleep disturbance. A variety of medications, suchs tricyclic antidepressants, selective serotonin reuptake in-ibitors, and cyclobenzaprine, may be effective in targetinghese symptoms. For detailed recommendations on the treat-ent of fibromyalgia, the reader is referred to guidelines

Maximum DosageDuration of AdequateTrial

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3600 mg daily (1200 mgtid); reduce if creatinineclearance less than 60mL/min

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s75-150 mg daily; if bloodlevel of active drug andits metabolite is below100 ng/ml, continuetitration with caution

6-8 weeks with at least1-2 weeks at maximumtolerated dosage

of postherpetic neuralgia and peripheral neuropathy in older adults.d Management, Vol. 35. Seattle, Washington: IASP Press; 2005:365, with, Allen RR, Argoff CR, Backonja M, et al. Arch Neurol. 2003;60:1524-1534.

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314 The American Journal of Medicine, Vol 120, No 4, April 2007

ith refractory symptoms should be referred for interdisci-linary treatment that may include cognitive-behavioralherapy, instruction in flare self-management techniquesnd how to pace engagement in aerobic exercise, and meth-ds to enhance sleep hygiene. Recently pregabalin also haseen approved.

eripheral Neuropathyefinition and Pathogenesis. Neuropathic pain is defined

s pain “initiated or caused by a primary lesion or dysfunc-ion in the nervous system.”16 The most common causes inlder adults are diabetes mellitus and reactivation of herpesoster (ie, postherpetic neuralgia). Axial arthritis (eg, cer-ical and lumbar spondylosis) associated with radiculopathys also considered by many experts to be a form of neuro-athic pain. Other causes of peripheral neuropathy in olderdults include alcoholic polyneuropathy, chemotherapy-in-uced polyneuropathy, entrapment neuropathies, postmas-ectomy pain, post-thoracotomy pain, nerve compression ornfiltration by tumor, phantom limb pain, postradiation plex-pathy, and trigeminal neuralgia.17 Central poststroke painay also present with symptoms that mimic peripheral

europathy.

valuation. Although several specialized tests are availableor the assessment of neuropathic pain, such as quantitativeensory testing and electromyography/nerve conduction, theistory and physical examination remain the cornerstone ofhe evaluation. Patients with peripheral neuropathy oftenomplain of constant or intermittent pain (typically worse atight and with inactivity), stimulus evoked-pain such as

Table 7 Guiding Principles for Caregivers of Older Adultswith Chronic Pain and Comorbid Dementia

● Chronic nonmalignant pain is not in and of itself harmful,and should not preclude performing routine activities.

● Try to use distraction as much as possible to lessenpatient’s focus on pain.

● If anxiety is a prominent component of pain behavior, usegentle touch (eg, rubbing the person’s back) in an effortto calm the patient.

● Ask the patient’s primary provider or physical therapistabout available nonpharmacologic approaches to painmanagement (eg, gentle massage, balms and ointments,relaxation techniques). Systemic pharmacologic agentsfraught with potential toxicities should be avoided asmuch as possible, although judicious and carefullymonitored use of these agents should be considered on acase by case basis.

● The caregiver and patient should try performing relaxationexercises together to diminish stress of both parties.

● The caregiver should try to be supportive and reassuringwhen the patient voices pain complaints. These complaintsshould not be brushed off, but attended to in a positiveway.

C

llodynia or hyperalgesia, pruritis or tingling, and sensoryoss. A comprehensive neurological examination should beerformed on all older adults with neuropathic pain. Whenhe cause is not obvious (eg, postmastectomy pain, post-horacotomy pain), a thorough general physical examinationhould be performed and any signs of malignancy should beursued diagnostically. If no cause can be found, the fol-owing laboratory studies should be obtained: vitamin B12nd folate levels, fasting blood glucose, and serum/urinelectrophoresis. If a cause still cannot be identified, theatient should be referred to a neurologist.

reatment. Neuropathic pain is typically more refractory toreatment efforts than nociceptive pain. A number of phar-acologic options are available. Tables 5 and 6 summarizeedications and dosing guidelines for the treatment of neu-

opathic pain.

HE ROLE OF DEPRESSION AND DEMENTIA INAIN MANAGEMENT

n 1965, the Gate Control Theory of Pain was born, and itsrinciples continue to guide pain management practice to-ay. This theory emphasizes the central role of the brain inain processing and accounts for the effectiveness of cog-itive behavioral therapy in management of chronic pain.hen the brain functions abnormally, as in the case of

epression or dementia, pain control becomes more chal-enging. Thus, practitioners that care for older adults withhronic pain must be as aggressive about recognizing andreating these disorders as they are about the pain itself.

While depression is eminently treatable, the presence ofementia in the older adult with chronic pain poses a con-iderable challenge. Often, those with dementia have exag-erated fear responses to pain which, in turn, can intensifyhe pain experience. The pharmacologic and nonpharmaco-ogic modalities that have already been discussed shouldlso be offered to the older adult with dementia. Educationhould be emphasized, especially education of caregivers.

Table 8 Treatment Outcome Parameters for the Older Adultwith Chronic Pain

Pain interference with performance of:● Basic activities of daily living● Instrumental activities of daily living● Discretionary activitiesMobility/activity levelEnergy levelAppetiteSleepMood – eg, irritability, depressionInterpersonal interactionsAttention and concentrationFrequency of prn analgesic ingestionPain severity

omponents of care-giver education are provided in Table 7.

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OW TO DETERMINE WHETHER PAINREATMENT IS EFFECTIVEain intensity is only one of many parameters that may

mprove when chronic pain is managed successfully. Pa-ients with chronic nonmalignant pain should anticipate, onverage, no more than 30%-50% reduction in pain intensity.hysical function, mood, endurance, sleep, appetite, and

nterpersonal interactions may respond even more substan-ially to treatment, as may overall quality of life. As part ofhe initial assessment, therefore, the practitioner shouldlearly identify treatment goals in order to determine theffectiveness of therapy. Although treatment goals must bendividualized, a list of potential outcome parameters isrovided in Table 8.

OW AND WHEN TO REFER TO AAIN SPECIALISThe decision regarding when and to whom to refer the olderdult with refractory pain depends upon the patient’s goals.n general, referral to a pain specialist should be consideredhen the patient continues to experience disabling painespite efforts to control symptoms with medications andther therapeutic modalities (eg, injections, physical ther-py). Pain specialists also vary widely in their training andpproach to treatment. Some specialists focus exclusivelyn injection procedures, while others work with an interdis-iplinary team that utilizes a rehabilitative approach. Be-ause of the multifactorial nature of chronic pain syndromesn older adults, the latter strategy is favored and appears toe most effective.

eferences1. Simons DG, Travell JG, Simons LS, eds. Travell & Simons’ Myofas-

cial Pain and Dysfunction—The Trigger Point Manual, Volume I.Upper Half of Body, Volume II. Lower Half of Body. Second Ed.Baltimore: Williams & Wilkins; 1999.

2. Gunn CC. Neuropathic myofascial pain syndromes. In: Loeser JD,Butler SH, Chapman CR, et al. Bonica’s Management of Pain. Third
Ed. Philadelphia: Lippincott Williams & Wilkins; 2001.
3. Gerwin RD. Classification, epidemiology, and natural history of myo-fascial pain syndrome. Curr Pain Headache Rep. 2001;5:412-20.

4. Borg-Stein J. Treatment of fibromyalgia, myofascial pain, and relateddisorders. Phys Med Rehab Clin North Am. 2006;17:491-510.

5. Hong CZ. Lidocaine injection versus dry needling to myofascial trig-ger point: the importance of the local twitch response. Am J Phys MedRehab. 1994;73:256-63.

6. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain withemphasis on imaging. Ann Intern Med. 2002;137:586-97.

7. Jarvik JJ, Hollingworth W, Heagerty P, Haynor DR, Deyo RA. Thelongitudinal assessment of imaging and disability of the back(LAIDBack) study: baseline data. Spine. 2001;26:1158-66.

8. Airaksinen O, Herno A, Turunen V, Saari T, Suomlainen O. Surgicaloutcome of 438 patient treated surgically for lumbar spinal stenosis.Spine. 1997;22:2278-82.

9. Frazier DD, Lipson SJ, Fossel AH, Katz JN. Associations betweenspinal deformity and outcomes after decompression for spinal stenosis.Spine. 1997;22:2025-9.

0. Prestwood K. Complementary and alternative medicine approaches topain in older persons. In: Gibson SJ, Weiner DK, eds. Pain in OlderPersons, Progress in Pain Research and Management. Seattle: IASPPress; 2005.

1. American Geriatrics Society Panel on Exercise and Osteoarthritis.Exercise prescription for older adults with osteoarthritis pain: Consen-sus practice recommendations. J Am Geriatr Soc. 2001;49:808-23.

2. Bernstein CD, Lateef B, Fine PG. Interventional pain managementprocedures in older patients. In: Gibson SJ, Weiner DK, eds. Pain inOlder Persons, Progress in Pain Research and Management. Seattle:IASP Press; 2005:263-83.

3. AGS Panel on Persistent Pain in Older Persons. The Management ofPersistent Pain in Older Persons. American Geriatrics Society. J AmGeriatr Soc. 2002;50:S205-S224.

4. Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. The prevalence andcharacteristics of fibromyalgia in the general population. ArthritisRheum. 1995;38:19-28.

5. Burckhardt C, Goldenberg DL, Crofford L, et al. Guideline for theManagement of Fibromyalgia Syndrome Pain in Adults and Chil-dren—APS Clinical Practice Guidelines Series. Fourth Ed. Glenview,Illinois: American Pain Society; 2005.

6. Turk DC, Okifuji A. Pain terms and taxonomies of pain. In: Loeser JD,ed. Bonica’s Management of Pain. Third Ed. Philadelphia: LippincottWilliams & Wilkins; 2001:17-25.

7. Schmader KE, Dworkin RH. Clinical features and treatment of post-herpetic neuralgia and peripheral neuropathy in older adults. In: Gib-son SJ, Weiner DK, eds. Pain in Older Persons, Progress in Pain
Research and Management. Seattle: IASP Press; 2005:355-75.

chronic pain

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