Sunday 12 May 2013

Pain in the older person

Older people are different. The physiological changes that occur with ageing, the co-morbidities, prescription of medication, frailty and psychosocial changes mean that  considering pain control for these individuals can be challenging.  The British Geriatric Society and British Pain Society have made some recommendations 
For many analgesic medicines, a lower initial dose may be required than prescribed for younger adults and should be titrated to response. The first line pharmacological treatment, particularly in musculoskeletal pain is paracetamol. It has demonstrated efficacy and a good safety profile, but it is important that the maximum daily dose is not exceeded. Although NSAIDs are effective analgesics, their side effect profile requires cautious use. If essential, the lowest dose should be used for the shortest period and reviewed regularly. Opioids are effective in the short term, but evidence for long-term efficacy is much more limited and hence patients prescribed opioids should have regular review, both for efficacy and tolerability. Side effects, particularly constipation, should be anticipated and prophylactic treatments prescribed. Excessive sedation can be problematic and should be monitored carefully. Tricyclic antidepressants or anti-epileptics may be considered for neuropathic pain, although side effects often limit their use. Topical analgesics have a role in localised pain; both lidocaine and capsaicin have limited efficacy in localised neuropathic pain and topical NSAIDs may be suitable for non-neuropathic pain.
Combination therapy using different classes of analgesics may provide greater pain relief through synergistic action with fewer side effects compared with higher doses of a single medicine.

Interventional therapies

Interventional therapies in the management of chronic pain include a variety of neural blocks and minimally invasive procedures. The recommendations produced in this section are limited to specific interventions in clinical conditions common in older people. Intra-articular (IA) corticosteroid injection in osteoarthritis of the knee is effective in relieving pain in the short term with little risk of complications and/or joint damage. Hyaluronic acid is also effective but appears to have a slower onset of action and lasts longer than steroids. The evidence for IA injection of other joints, however, is limited.
The evidence for facet joint interventions is mixed, although there is some support for radiofrequency lesioning for both cervical and lumbar facet joint pain in appropriately selected patients. There is also limited data to support consideration of epidural steroid injections 

Psychological interventions

It is well recognised that psychological factors often influence the manner people respond to and cope with pain, and techniques may modify beliefs and attitudes. However, few studies have focused on older adults and sample sizes are small. Nonetheless, psychological interventions such as cognitive behavioural therapy (CBT) or behavioural therapy may be effective in decreasing chronic pain in adults and improving disability and mood. Elderly nursing home residents with chronic pain may benefit from CBT pain management interventions. Psychological interventions may be used as an adjunct to pharmacological intervention and/or other modalities.
 Physical activity

 Physical activity and assistive devices encompass a wide range of

interventions. The available evidence supports the use of programmes that

comprise strengthening, flexibility and endurance activities to increase

 physical activity, improve function and pain.]There are many different forms of

exercise and the choice of exercise type can pose a dilemma. Given the

 absence of evidence to recommend one type of exercise over another,

 patient preference should be a key factor and programmes should be

customised to individual capacity and need.  A large range of potential

options includes progressive resistance exercise, walking, water-based

exercise/hydrotherapy. Golf , bowls and adaptations of Tai-Chi and Yoga  and

advances in gaming technology such as Wii are also opening up new

possibilities and are useful in balance control

 Complementary therapies

Some types of complementary therapy [e.g. acupuncture, transcutaneous electrical nerve stimulation (TENS), massage] have been used for older adults with painful conditions, although the available studies lack methodological rigour. Acupuncture applied singularly or in combination with other modalities has an impact on pain and quality of life in patients with osteoarthritis. Conventional TENS can be used for relief of musculoskeletal pain. Similarly, percutaneous electrical nerve stimulation combined with physiotherapy reduces pain and self-reported disability for up to 3 months. Other therapies such as massage can be used to treat chronic pain, in particular shoulder or knee pain.