Pharmacotherapeutic management of pain with a focus directed at the geriatric patient

Twenty percent to 50% of geriatric noninstitutionalized patients are victimized by pain that can result from multiple chronic medical and psychiatric diseases. This article discusses recognizing the barriers that the clinician encounters in evaluating pain in geriatric patients, taking a pain and pain medication history, and establishing a treatment plan to address the patient's experience of pain. It discusses dosage modifications appropriate for the geriatric population and reviews the drugs available to alleviate pain.     

Management of chronic pain in old patients: Belgium,Spain and Switzerland

The prevalence of chronic pain increases with age, although solid and comparable epidemiological data addressing the oldest old and specific settings are still sparse. Chronic pain is associated with multimorbidity, disability and reduced quality of life. However, in many cases it goes undetected, it is not adequately screened and assessed, and treatment is suboptimal. Most drugs used for pain treatment carry a higher risk of side effects in older subjects. This paper explores the epidemiology, screening, diagnosis and management of chronic pain in old age in three European countries. Chronic pain may go undiagnosed, as screening programs for identification of this problem are yet uncommon, both in community care and in hospitals and nursing homes. Pain assessment is increasingly (but not universally) a part of comprehensive geriatric assessment, and most geriatricians receive training and seem to be confident in the diagnosis and management of chronic pain in complex or frail patients. Primary care physicians are usually the first providers to manage chronic pain, and only some patients are referred for specialist care. Pain clinics are widely available in the three countries, but older patients do not usually reach them. Acetaminophen is the mainstay of treatment of chronic pain, with reducing – but yet significant – use of NSAIDs and increasing use of weak opioids, mostly tramadol. Strong opioids are not widely used in older subjects, and concerns about side effects and on the choice of drugs in chronic renal disease are still present. Non-pharmacological therapies are not standardised. Attitudes towards chronic pain may hinder identification and management of this highly prevalent geriatric problem.     

Geriatric shoulder pain: common causes and their management

Shoulder pain in the geriatric patient is a common presentation encountered by primary care physicians. Proper evaluation requires an understanding of the pertinent anatomy, a thorough physical examination, and a knowledge of common shoulder disorders that occur in this population. This article provides information needed to evaluate the geriatric patient with shoulder pain. Common causes of shoulder pain--both intrinsic and extrinsic--and their management will be reviewed.     

Comprehensive management of chronic pain in haemophilia

Chronic pain, most often due to haemophilic arthropathy, is a pervasive problem in persons with haemophilia (PWH) that adversely impacts function and quality of life. PWH with inhibitors and older PWH may be especially vulnerable to progressive arthropathy and resulting chronic pain. The development of chronic pain from acute pain involves a complex interplay of biological and psychosocial factors that may all contribute to the perpetuation of chronic pain and the outcome of therapy. In the absence of evidence‐based guidelines, an individualized, multimodal approach to chronic pain management is proposed, as it is in individuals without haemophilia who have chronic pain. Pharmacological treatment is central to the management of chronic pain and must be modified based on pain intensity, ongoing response to therapy and the risk for adverse events. Non‐pharmacological interventions, including physiotherapy, complementary treatments and surgical (e.g. orthopaedic) or other invasive procedures, may be integral to chronic pain management in this population. Ongoing psychosocial assessment is critical to identify those factors that may be contributing to the perpetuation of chronic pain or acting as barriers to effective management. Additional study is needed to identify optimal pharmacological treatments for chronic pain in PWH based on the unique pathophysiology of haemophilic arthropathy and on risk profile. Systematic determination of the particular psychosocial factors impacting the experience and management of chronic pain in PWH would likewise add value to the treatment of this pervasive problem.     

Management of musculoskeletal pain

Chronic musculoskeletal pain is a major public health problem affecting about one third of the adult population. Pain is often present without any specific findings in the musculoskeletal system and a strictly biomedical approach could be inadequate. A biopsychosocial model could give a better understanding of symptoms and new targets for management. Identification of risk factors for chronicity is important for prevention and early intervention. The cornerstones in management of chronic non-specific, and often widespread, musculoskeletal pain are non-pharmacological. Physical exercise and cognitive behavioral therapy, ideally in combination, are first line treatments in e.g. chronic low back pain and fibromyalgia. Analgesics are useful when there is a specific nociceptive component, but are often of limited usefulness in non-specific or chronic widespread pain (including fibromyalgia). Antidepressants and anticonvulsants could be of value in some patients but there is a need for more knowledge in order to give general recommendations.     

Acute abdominal pain in geriatric patients evaluated in the emergency room at a third level hospital

"Background: Life expectancy in México has increased in the last decades with a remarkable increase in geriatric population. Acute abdominal pain (AAP) in elderly people compared with young people has different clinical presentation because of the concomitant chronic diseases, the use of medications, history of abdominal surgeries and decrease in perception of pain and immunity. Objective: To know the cause and associated mortality of acute abdominal pain in geriatric patients who attend the emergency room. Methods: Geriatric patients' files with acute abdominal pain admitted from January 2004 to December 2008 were retrospectively reviewed. Age, gender, presence of chronic diseases, use of medications, history of surgical procedures, definitive diagnosis causative of the symptoms and the associated mortality were recorded. Results: 17 524 patients were admitted, of whom 324 (1.8%) were geriatric patients with AAP: 110 were men (36.9) and 214 were women (66%), with a mean age of 78 years (range 60 to 102 years). The most common causes of AAP were acute cholecystitis in 49 patients (15.1%), irritable bowel syndrome in 42 (12.9%), ulcerative syndrome in 40 (12.3%), intestinal obstruction in 35 (10.8%) and diverticulitis in 23 (10.8%). Nine patients died (2.7%). Conclusions: In our hospital the most common cause of AAP in geriatric patients is related to biliary disease followed by functional gastrointestinal disorder and ulcerative syndrome. Mortality is low."     

A geriatrician's guide to the use of the physical modalities in the treatment of pain and dysfunction

The use of the physical modalities in the treatment of musculoskeletal conditions has a long and rich history. This article explores the various physical modalities and their indications, precautions, and contraindications, especially in their applied use in pain management. It also highlights the role of the physical modalities as agents for the management of pain in the geriatric population.     

Principles of perioperative pain management in older adults.

The consequences of poor planning for pain management during surgery of geriatric patients not only affect the immediate well-being of the patient but also have terrible socioeconomic implications. Delays in rehabilitation, increases in hospital lengths of stay, and increased comorbidity can be expected if interventions for pain management are either inadequate or excessive without appropriate monitoring. During surgery, seniors are likely to suffer from acute and chronic pain that must be addressed aggressively in the postoperative period to ensure a rapid functional recovery. New pain scales have been developed with seniors in mind, and greater testing of older scales in elderly populations have helped to identify measures of pain more suited to frail seniors. This article is designed to help clinicians to strategically implement optimal pain management principles and techniques and, thus, help to fulfill the obligation to relieve pain and suffering in patients in the perioperative period, which will ensure the greatest chance of recovery to optimal independence for patients.     

Pain management at home.

The management of chronic pain should be a priority in geriatric home care. Pain is a common problem that has tremendous potential to influence the physical function and quality of life of elderly people during their remaining years. The experience of pain and its management at home are not analogous to institutional settings. Family and caregivers have important influences on pain management and may require education and support for the long-term management of chronic pain patients. Existing pain management strategies should be tailored to meet the special needs of geriatric patients and be sensitive to caregiver concerns. Implications, indications, and applications for high-tech pain management strategies need to be clarified for the management of older people at home.     

Cardiac pain in geriatrics

The atypical symptoms of coronary heart disease combined with an altered pain threshold and pain sensitivity in older patients make it difficult for the geriatrician to diagnose this disease. Clinical diagnostic methods cannot always be used in older patients. Therefore the physician must have a heightened awareness for unspecific symptoms which can signal coronary heart disease in the geriatric patient. In addition one must also use specific geriatric considerations in the management of angina pectoris.     

A comparison of coping strategies in chronic pain patients in different age groups

This study examined the effects of age on the frequency of use and perceived effectiveness of coping strategies in patients having chronic pain. Subjects were chronic pain patients in four age groups (young, middle, older, and geriatric). All subjects completed the Coping Strategies Questionnaire, which measures the use and perceived effectiveness of a variety of cognitive and behavioral coping strategies in controlling and decreasing pain. Subjects also completed measures of pain, depression, and psychological distress. Data analysis revealed that there were no significant age differences in either the use or perceived effectiveness of pain coping strategies. Correlational analyses based on data combined from the different age groups suggested that, while certain pain coping strategies appear to be adaptive (e.g., coping self-statements), other coping strategies appear to be maladaptive (e.g., catastrophizing, diverting attention, increasing behavioral activities). Patients who rated their ability to decrease pain as relatively high, reported lower levels of depression and pain. These findings are consistent with a contextual perspective on coping which postulates that few, if any, age differences in coping are to be expected when individuals are coping with a similar life event.     

Pharmacological pain management in chronic pancreatitis

Intense abdominal pain is a prominent feature of chronic pancreatitis and its treatment remains a major clinical challenge.Basic studies of pancreatic nerves and experimental human pain research have provided evidence that pain processing is abnormal in these patients and in many cases resembles that seen in neuropathic and chronic pain disorders.An important ultimate outcome of such aberrant pain processing is that once the disease has advanced and the pathophysiological processes are firmly established,the generation of pain can become self-perpetuating and independent of the initial peripheral nociceptive drive.Consequently,the management of pain by traditional methods based on nociceptive deafferentation(e.g.,surgery and visceral nerve blockade)becomes difficult and often ineffective.This novel and improved understanding of pain aetiology requires a paradigm shift in pain management of chronic pancreatitis.Modern mechanism based pain treatments taking into account altered pain processing are likely to increasingly replace invasive therapies targeting the nociceptive source,which should be reserved for special and carefully selected cases.In this review,we offer an overview of the current available pharmacological options for pain management in chronic pancreatitis.In addition,future options for pain management are discussed with special emphasis on personalized pain medicine and multidisciplinarity.     

Management of chronic pain in the elderly: focus on transdermal buprenorphine

Chronic pain in the elderly is a significant problem. Pharmacokinetic and metabolic changes associated with increased age makes the elderly vulnerable to side effects and overdosing associated with analgesic agents. Therefore the management of chronic cancer pain and chronic nonmalignant pain in this growing population is an ongoing challenge. New routes of administration have opened up new treatment options to meet this challenge. The transdermal buprenorphine matrix allows for slow release of buprenorphine and damage does not produce dose dumping. In addition the long-acting analgesic property and relative safety profile makes it a suitable choice for the treatment of chronic pain in the elderly. Its safe use in the presence of renal failure makes it an attractive choice for older individuals. Recent scientific studies have shown no evidence of a ceiling dose of analgesia in man but only a ceiling effect for respiratory depression, increasing its safety profile. It appears that transdermal buprenorphine can be used in clinical practice safely and efficaciously for treating chronic pain in the elderly.     

Systematic mechanism-orientated approach to chronic pancreatitis pain

Pain in chronic pancreatitis(CP) shows similarities with other visceral pain syndromes(i.e.,inflammatory bowel disease and esophagitis),which should thus be managed in a similar fashion.Typical causes of CP pain include increased intrapancreatic pressure,pancreatic inflammation and pancreatic/extrapancreatic complications.Unfortunately,CP pain continues to be a major clinical challenge.It is recognized that ongoing pain may induce altered central pain processing,e.g.,central sensitization or pro-nociceptive pain modulation.When this is present conventional pain treatment targeting the nociceptive focus,e.g.,opioid analgesia or surgical/endoscopic intervention,often fails even if technically successful.If central nervous system pain processing is altered,specific treatment targeting these changes should be instituted(e.g.,gabapentinoids,ketamine or tricyclic antidepressants).Suitable tools are now available to make altered central processing visible,including quantitative sensory testing,electroencephalograpy and(functional) magnetic resonance imaging.These techniques are potentially clinically useful diagnostic tools to analyze central pain processing and thus define optimum management approaches for pain in CP and other visceral pain syndromes.The present review proposes a systematic mechanism-orientated approach to pain management in CP based on a holistic view of the mechanisms involved.Future research should address the circumstances under which central nervous system pain processing changes in CP,and how this is influenced by ongoing nociceptive input and therapies.Thus we hope to predict which patients are at risk for developing chronic pain or not responding to therapy,leading to improved treatment of chronic pain in CP and other visceral pain disorders.     

Managing chronic pain in adults with haemophilia: current status and call to action

Haemophilic arthroses are associated with acute pain during bleeding episodes and with chronic pain caused by arthritic complications of repeated bleeding into joints. Unlike other conditions (e.g. osteoarthritis, rheumatoid arthritis, sickle cell disease), there are limited data on pain management in haemophilia. Management of arthritic individuals and those with sickle cell disease relies heavily on administration of acetaminophen, non‐steroidal anti‐inflammatory drugs (NSAIDs) and opioid analgesics. In haemophilia, acetaminophen often has limited efficacy at therapeutic doses, offering a narrow dosing range in those with liver disease due to chronic hepatitis C. NSAIDs can effectively manage pain in patients with haemophilia, but these agents are potentially associated with a significant risk of precipitating or exacerbating bleeding complications in an already coagulopathic population. Opioids have proven effective in osteoarthritis and sickle cell disease, but outcomes data in those with haemophilia are virtually non‐existent. Patients with haemophilia are at least as vulnerable as other chronic pain populations to opioid‐related adverse events and to developing abusive behaviours and addiction. Despite pain management strategies for patients with haemophilia being far from optimal, the predominant precept of haemophilia management still applies. As such, it is critically important to aggressively reverse or prevent acute symptomatic bleeding in a timely and effective manner to at least minimize pain and progressive joint damage. This review should serve as a call to action to prioritize pain management in haemophilia care and spur interest in the development, improvement and standardization of tools to assess and manage acute and chronic pain in haemophilia.     

Fibromyalgia and chronic widespread pain in autoimmune thyroid disease

Fibromyalgia and chronic widespread pain syndromes are among the commonest diseases seen in rheumatology practice. Despite advances in the management of these conditions, they remain significant causes of morbidity and disability. Autoimmune thyroid disease is the most prevalent autoimmune disorder, affecting about 10 % of the population, and is a recognized cause of fibromyalgia and chronic widespread pain. Recent reports are shedding light on the mechanisms of pain generation in autoimmune thyroid disease-associated pain syndromes including the role of inflammatory mediators, small-fiber polyneuropathy, and central sensitization. The gradual elucidation of these pain pathways is allowing the rational use of pharmacotherapy in the management of chronic widespread pain in autoimmune thyroid disease. This review looks at the current understanding of the prevalence of pain syndromes in autoimmune thyroid disease, their likely causes, present appreciation of the pathogenesis of chronic widespread pain, and how our knowledge can be used to find lasting and effective treatments for the pain syndromes associated with autoimmune thyroid disease.     

Physical therapy and exercise in pain management.

Physical therapy and exercise are fundamental to the interdisciplinary approach to pain management in the elderly. Physical modalities used in combination with exercise provide pain relief and help to prevent future pathology and physiologic changes in the elderly that often result in significant pain syndromes. This article provides an overview of effective modalities for pathology prevention, treatment of pain, and restoration of function that are the basis for pain management in geriatric patients.     

Chronic pain and fibromyalgia: the regulatory perspective

Chronic pain is an important clinical entity that represents a currently unmet medical need. Relief of pain is an important public health goal for patients of all ages, from perinatal to geriatric. This article will describe some of the current regulatory issues in developing and approving drugs to treat chronic pain. It will also begin to familiarize the reader with the importance of the so-called 'label' and some of its roles to enable the best 'risk-benefit' decisions be made for, and by, patients with chronic pain.