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 

Pharmacology

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.

Physical Therapy as Effective as Surgery for Meniscal Tear

Patients with knee osteoarthritis and a meniscal tear who received physical therapy without surgery had good functional improvement 6 months later, and outcomes did not differ significantly from patients who underwent arthroscopic partial meniscectomy, a new trial shows.

Patients with a meniscal tear and osteoarthritis pose a treatment challenge because it is not clear which condition is causing their symptoms.

Currently, millions of people are being exposed to potential risks associated with a surgical treatment that may or may not offer specific benefit, and the costs are substantial.

The physical therapy in both regimens  involved 1 or 2 sessions a week for about 6 weeks and home exercises. The average number of physical therapy visits was 7 in the surgery group and 8 in the non-surgery group.

 Mean Improvement in Osteoarthritis Index at 6 Months

Treatment Group	Mean Improvement (Points)	95% Confidence Interval
Surgery+ physical therapy	20.9	17.9–23.9
Physical therapy	18.5	15.6–21.5

The 12-month results were similar to the 6-month results. 

 John Mays, MD, an orthopaedic surgeon practicing in  Louisiana, USA, who was asked to comment on the findings, said most patients don't choose physical therapy. "In the real world, most people want a quick fix" and choose surgery, he noted.

Dr. Mays said he would have liked to have seen a group of patients who underwent surgery but did not receive postoperative physical therapy. He explained that his patients with osteoarthritis and meniscal tear rarely get physical therapy after arthroscopic meniscectomy; they most often do home-based exercises.

He added that "most insurance plans have limits on the number of physical therapy sessions they allow."

N Engl J Med. Published online March 19, 2013. Abstract, Editorial

Being active increases survival rates from colorectal cancer

The more you walk the more likely you are to survive after being diagnosed with colorectal cancer. 

In a study of 2293 patients who developed colorectal cancer it was shown the more you walked and were active, the more likely you were to survive from this disease. The less activity you did the more likely you were to die from it. "Get out of that chair" was the message from this study.

This data further strengthen current recommendations to participate in at least 2.5 hours of walking per week for colorectal cancer survivors. 

Campbell PT, Patel AV, Newton CC, Jacobs EJ, Gapstur SM

J Clin Oncol. 2013;31:876-885

Widely Used Diclofenac Associated With Increased Risk for Cardiovascular Events

The nonsteroidal anti-inflammatory drug (NSAID) diclofenac, a drug that is frequently used for the treatment of pain and inflammation caused by arthritis, is associated with a significantly increased risk of cardiovascular complications and should be removed from essential-medicines lists (EML), according to a newreview [1].

Diclofenac, which is listed on the EML of 74 countries, increased the risk of cardiovascular events between 38% and 63% in different studies. The increased risk with diclofenac was similar to the COX-2 inhibitor rofecoxib (Vioxx, Merck), a drug withdrawn from worldwide markets because of cardiovascular toxicity.

"We could find no-risk doses with some of the other drugs, like ibuprofen, naproxen, and celecoxib [Celebrex, Pfizer],"

Fitness Linked to Lower Dementia Risk

We need to do about  75  minutes of vigorous activity a week or 150 minutes of moderate activity.

Higher fitness levels in midlife are associated with a lower risk for dementia in later life, a new study suggests.

"We already know exercise has cardiovascular and many other benefits, but this may give people more incentive to get moving," lead author, Laura F. DeFina, MD,  "Dementia is the second most feared disease after cancer, and our research suggests you can lower your risk by keeping fit."

The study is published in the February 5 issue of the Annals of Internal Medicine.

The study included 19,458 individuals participating in the Cooper Clinic Longitudinal Study at the Cooper Institute, a preventive medicine clinic. All underwent standardized fitness testing in midlife (median age, 49.8 years) and were then followed for an average of 25 years. 

There were 1659 cases of all-cause dementia reported. After multivariable adjustment, participants with the highest fitness level  at midlife had a 36% reduction in risk of developing dementia from any cause during follow-up than those in the lowest fitness category 

Dr. DeFina also pointed out that the reduction in dementia was consistent in patients who had had a stroke and in those who hadn't, suggesting that the mechanism does not just involve vascular disease. "Exercise is known to reduce cardiovascular disease, which we would expect to be translated into benefit on stroke, but because we also saw a similar reduction in dementia with improved fitness in patients who hadn't had a stroke, this suggests that other mechanisms are also involved."

She added that animal studies have suggested that increased fitness and activity correlates with a reduction in brain atrophy and loss of cognition, and changes in amyloid have been seen with regular activity.

Although this was a study of fitness, rather than actual physical activity undertaken, Dr. DeFina said the results were consistent with US physical activity guidelines that recommend 150 minutes of moderate exercise or 75 minutes of vigorous activity per week for health benefits.

Tennis Elbow: No Long-Term Benefit From PT, Corticosteroids

What is  best practice for treatment of tennis elbow is a knotty issue. Studies continue to try to unravel this. A recent piece of research published showed little long term benefits of physio but it was stated that they:

 "... believe strongly in physical therapy for tennis elbow, both to help the patient through the acute phase of the injury and to provide the patient with exercises/knowledge to prevent reinjury down the line".  "In many cases, patients will benefit considerably just from knowledge gained in physical therapy. If they apply this knowledge consistently, they may achieve better long-term outcomes,"

Below is an abstract of this work:

A steroid injection and 2 months of physical therapy may not be the solution for lateral epicondylalgia, commonly known as tennis elbow, suggest research findings published in the February 5 issue of JAMA.

Brooke K. Coombes, PhD, from the University of Queensland, St. Lucia, Australia, and colleagues found that patients treated with a single corticosteroid injection had a 14% greater chance of poor outcome and a 77% increased risk for reinjury at 1 year relative to placebo.

Eight weeks of physical therapy appeared to have no long-term benefit with the exception of decreased analgesic use. However, the physical therapy did improve short-term pain and disability outcomes at 1 month, although those benefits were lost when steroid injection was added to the treatment.

JAMA. 2013;309:461-469. 

Skin, Joint, and Back Problems Prompt Most Physician Visits

FYI

Most patients without acute conditions see their physicians not because of diabetes, heart disease, or cancer but because of skin problems, joint disorders, and back pain, according to an article published in the January 2013 issue of Mayo Clinic Proceedings.

Jennifer L. St. Sauver, PhD, MPH, from the Division of Epidemiology, Mayo Clinic Center for the Science of Health Care Delivery, Rochester, Minnesota, and colleagues analyzed the medical records of residents of Olmstead County, Minnesota, as of April 1, 2009

They say, "Finding that skin and back problems are major drivers of health care utilization affirms the importance of moving beyond the commonly recognized health care priorities such as diabetes, heart disease, or cancer," the researchers conclude. "Our findings highlight opportunities to improve health care and decrease costs related to common non-acute conditions as we move forward through the changing health care landscape."