Pharmacological pain management in the elderly patient

With the increasing number of elderly patients the issue of pain management for older people is of increasing relevance. The alterations with aging of the neurobiology of pain have impacts of pain threshold, tolerance and treatment. In this review the available evidence from animal and human experimentation is discussed to highlight the differences between young and older subjects along with consideration of how these changes have practical effect on drug treatment of pain. Cognitive impairment, physical disability and social isolation can also impact on the accessibility of treatment and have to be considered along with the biological changes with ageing. Conventional pain therapies, while verified in younger adults cannot be automatically applied to the elderly without consideration of all these factors and in no other group of patients is a holistic approach to treatment more important.     

Office management of chronic pain in the elderly

Chronic pain plagues older adults more than any other age group; thus, practitioners must be able to approach this problem with confidence and skill. This article reviews the assessment and treatment of the most common chronic nonmalignant pain conditions that affect older adults—myofascial pain, generalized osteoarthritis, chronic low back pain (CLBP), fibromyalgia syndrome, and peripheral neuropathy. Specific topics include essential components of the physical examination; how and when to use basic and advanced imaging in older adults with CLBP; a stepped care approach to treating older adults with generalized osteoarthritis and CLBP, including noninvasive and invasive management techniques; how to diagnose and treat myofascial pain; strategies to identify the older adult with fibromyalgia syndrome and avoid unnecessary “diagnostic” testing; pharmacological treatment for the older adult with peripheral neuropathy; identification and treatment of other factors such as dementia and depression that may significantly influence response to pain treatment; and when to refer the patient to a pain specialist. While common, chronic pain is not a normal part of aging, and it should be treated with an emphasis on improved physical function and quality of life.     

Practical management of non-malignant pain in the elderly

The optimal management of chronic non-malignant pain in the elderly is founded first on comprehensive assessment and classification of the pain. The resulting pain diagnosis both targets appropriate areas for intervention and guides an often necessary multimodal approach to therapy. The indications for these various therapies, referral strategies, and guidelines for analgesic pharmacotherapy in the elderly are discussed.     

Behavioral approaches to pain management in the elderly

Pain is a complex phenomenon, influenced by many individual and external factors, and may be experienced differently with age. The detrimental health and social effects of chronic pain are well known. Age-related disorders, such as dementia, may interfere with the communication of pain. Health care provider bias and cultural expectations also may be barriers to the recognition and management of pain in the elderly. A multidisciplinary and multimodal approach in older adults is essential to effective assessment and management. Behavioral approaches to pain should be considered and incorporated into treatment where appropriate.     

老年人慢性疼痛治疗进展

慢性疼痛严重威胁着老年人的身心健康,其患病率之高令人惊讶.据澳大利亚国立衰老研究所(National Aging Research Institution,Australia)报道,在社区居住的老年人中有50%患有慢性疼痛;而在敬老院居住的老年人中慢性疼痛的患病率高达80%~([1]).遗憾的是老年人的慢性疼痛没有得到足够重视和合理治疗~([2]).疼痛治疗的欠缺常常会给老年人的健康带来严重的后果,导致各种生理功能的减弱或丧失,活动减少,日常生活严重依赖他人帮助.     

老年病人规范化疼痛治疗的原则

慢性疼痛在老年群体中发病率较高,因为老年人身体组织器官退化、免疫力低下,容易患有肿瘤、骨关节疾病及各种神经病理性疼痛,并可能严重影响正常的生理及运动功能,其中因骨折后疼痛的致死致残率较高。研究显示老年患者的疼痛发生率为25％-50％,其中约有45％-80％患有明显疼痛的患者需要长期治疗护理。随着我国及全球人口老龄化程度的日趋加重,关注老年人的身心健康,控制治疗疼痛,提高生活质量,是疼痛治疗领域里的一个新的重要课题。     

Back pain in the elderly: updated diagnosis and management

CT of compression fractures is a useful adjunct to the plain x-ray in excluding signs of metastasis. However, increased bone density on CT may not distinguish osteoporotic fractures from neoplastic disease, in which case radioiodine scan, bone and marrow biopsies, or myelography may be necessary. Surgery for painful osteoarthritic spinal disease is controversial. The potential advantages of surgery must be weighted against the risk of anesthesia, the length and tolerance of postoperative immobility, and the effect of laminectomy and fusion on the biomechanics of the spine. Furthermore, the elderly are at increased risk for postoperative complications.     

Neck pain in the elderly: common causes and management

Neck pain is common in the elderly. An outline of the relevant anatomy and pathological conditions which affect the cervical spine and an approach to diagnosis are presented. Intrinsic causes of pain arise in the vertebral column itself--arthritis, discogenic disorders, trauma, tumors, and infection; in the cervical musculature--myofascial pain syndrome, torticollis, and whiplash; and in the spinal cord from tumors. Differentiation of these causes from extrinsic causes of neck pain will enable the appropriate management protocols to be implemented. Many of these problems can be treated effectively at the primary care level. Guidelines for specialist referral are suggested.     

Hydrotherapy, balneotherapy, and spa treatment in pain management

The use of water for medical treatment is probably as old as mankind. Until the middle of the last century, spa treatment, including hydrotherapy and balneotherapy, remained popular but went into decline especially in the Anglo-Saxon world with the development of effective analgesics. However, no analgesic, regardless of its potency, is capable of eliminating pain, and reports of life-threatening adverse reactions to the use of these drugs led to renewed interest in spa therapy. Because of methodologic difficulties and lack of research funding, the effects of water treatments in the relief of pain have rarely been subjected to rigorous assessment by randomised, controlled trials. It is our opinion that the three therapeutic modalities must be considered separately, and this was done in the present paper. In addition, we review the research on the mechanism of action and cost effectiveness of such treatments and examine what research might be useful in the future.     

重视老年人的疼痛治疗工作

衰老是人生不可避免的生理过程。步入老年,除了心智更加成熟外,长年工作生活积累下来的很多疾病,也会逐步加重,并会以疼痛的形式表现出来。因此,很多老年人常年经受疼痛的折磨。且除非忍无可忍,大多数老年人仍多会选择忍受或自我服脂镇痛药的方法,而很少到医院就医。即便是到医院就医,也通常按部位来选择就诊科室,而诊疗科室更重视引起疼痛的原发疾病的治疗,往往忽略针对疼痛的治疗。诸多社会因素,导致老年人的疼痛治疗受到忽视。     

Low back pain in the elderly: practical management concerns

Low back pain occurs in 90% of the adult population. Previous episodes of low back pain in young adults predisposes to exacerbations and chronic problems in the elderly. Radiographic abnormalities demonstrating osteoarthrosis of the lumbar spine and facet joints and varying degrees of disk bulge and disk degeneration are the rule in both asymptomatic and symptomatic patients. Therefore, clinical assessments rather than purely morphological assessments are necessary to assess treatment plans and prognosis in elderly low back pain patients. Osteoarthritic changes are more often asymptomatic than symptomatic. CT and MRI demonstrations of spinal stenosis should be correlated with clinical findings to determine appropriate management decisions. Most elderly patients with low back pain with or without sciatica and with only radiographic CT or MRI rather than clinical evidence of spinal stenosis can be successfully managed conservatively.     

Dysphagia: causes, assessment, treatment, and management

Dysphagia, or difficulty in swallowing, is a condition with a strong age-related bias. Rates of dysphagia vary due to differences in method between studies; eg, clinical history of "swallowing difficulty," evidence of aspiration, or dysphagia confirmed by swallowing investigations. In general, the rate is lower in the community than in nursing home facilities. The management and treatment of dysphagia among geriatric patients is complicated by cognitive decline, lowered immunity, malnutrition, and end-of-life decisions. This article reviews the current assessment, treatment, and management techniques for dysphagia; covers new developments in research and pilot studies; and reviews the ethical issues related to treatment when prognosis is poor.     

Postoperative pain management in elderly patients: correlation between adherence to treatment guidelines and patient satisfaction

OBJECTIVES: To evaluate pain management satisfaction in elderly postoperative patients; to define pain management strategies documented in the medical record (MR) that predict patient satisfaction. DESIGN: Prospective cohort. SETTING: Eight urban hospitals. PARTICIPANTS: Three hundred twenty-two postsurgical patients aged 65 and older. MEASUREMENTS: Patients were surveyed regarding satisfaction with pain management in the first 24 hours postsurgery and the survey results summarized in a score. Pain management variables (patient education, pharmacological and nonpharmacological interventions, demographic variables, and surgery and anesthesia information) were abstracted from their MR. The correlation between the satisfaction score and MR variables was assessed using linear regression. RESULTS: Sixty-two percent of patients experienced severe postoperative pain, yet 87% reported being satisfied with the treatment. The mean satisfaction score+/-standard deviation was 59.3+/-10.8 (range 10.6-84.3; potential range 0-100, higher score=higher satisfaction). MR variables explained 14% of the satisfaction score variation. The worst pain intensity in the first 24 hours postsurgery as documented in the MR was the most powerful predictor of satisfaction. Other predictors associated with satisfaction were younger age, male sex, preoperative education, surgery type (laparotomy/thoracotomy patients were more satisfied than orthopedic patients), shorter recovery room stay, analgesic given through oral route, and morphine (compared with other opioids). CONCLUSION: Pain in elderly surgical patients remains undermanaged. Simple strategies such as emphasizing preoperative education may have a large effect in pain management. This study developed a validated patient satisfaction score and a MR instrument to assist in monitoring pain management quality.     

Experience assessment and management of pain in people with dementia

Pain is an inherently subjective experience that is difficult to prove. In a cognitively impaired older person whose verbal fluency is declining, both the experience and expression of pain are altered. Assessment poses many difficulties. Consequently the older person with dementia and pain may be under-treated and poorly managed. This review addresses each of these issues and makes recommendations for more effective care in the future. The search strategy for this review was carried out using Medline (1990-2002), Embase (1989-2001) and ClinPSYCH (1990-2001) databases. References cited within these sources were also reviewed. Searches were limited to English language studies. The quality of relevant studies retrieved was assessed and information from relevant papers synthesised using narrative summary.     

Neck pain in the elderly: a management review. Part I

Degenerative disease of the cervical spine is a common cause of neck pain in the elderly. This article reviews the pathogenesis, clinical features, and management of cervical spondylitic radiculopathy and myelopathy in the elderly.     

Neck pain in the elderly: a management review. Part II

Rheumatoid arthritis and metastatic cancer occur commonly in the elderly, and may cause neck pain. Rheumatoid arthritis may produce cervical radiculopathy and myelopathy resulting from vertebral body subluxation, although radiological manifestations of subluxation are much more common than neurological dysfunction. Cervical spinal cord compression is a neurological emergency and may produce cervical radiculopathy as well as myelopathy. Careful neurological and radiological assessments are required to minimize pain and preserve neurological function in elderly patients suffering from neck pain complicating rheumatoid arthritis or cervical spinal metastasis.