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Treatment of chronic non-cancer pain in older adults

Treatment of chronic non-cancer pain in older adults
Literature review current through: May 2024.
This topic last updated: Jan 31, 2024.

INTRODUCTION — The population of older adults (age 65 and older) is growing, with numbers of the frailest, most pain-ridden, and oldest (persons 85 years and over) increasing the most rapidly. Up to 50 percent of community-dwelling older adults report pain that interferes with normal function, and at least half of nursing home residents report pain on a daily basis [1,2]. Medical, psychological, and social comorbidities, as well as environmental factors, may contribute to pain and/or impact treatment response [3].

This topic will discuss treatment of chronic non-cancer pain in the older adult, with an emphasis on the differences in management from younger adults. Other closely related, important issues related to treatment of pain in older adults are reviewed in detail separately:

(See "Evaluation of chronic non-cancer pain in adults".)

(See "Approach to the management of chronic non-cancer pain in adults".)

(See "Drug prescribing for older adults".)

EFFECTS OF CHRONIC PAIN IN OLDER PATIENTS — Pain may contribute to homeostenosis (ie, the progressive and gradual decline in physiological reserve with aging) and amplify frailty [4,5]. (See "Normal aging", section on 'Age-associated physiologic changes'.)

Chronic pain may be associated with impaired physical function [6], falls [7], diminished appetite [8], dysmobility, sleep disruption [9,10], depression and anxiety [11,12], agitation [13], and delirium [14], as well as more subtle decrements in cognitive function [15-18]. On the other hand, many older adults function well despite chronic pain, and the degree to which pain interferes with function is largely related to the individual's burden of biopsychosocial comorbidities [19]. Among older adult nursing home residents, mental health disorders (dementia, other serious mental illness, depressive disorders, posttraumatic stress disorder, and substance use disorders) may also influence their pain severity, frequency and interference trajectory [20].

GENERAL APPROACH — Chronic pain is defined as pain that continues beyond the expected time of healing, or for at least three to six months [21]. Prescribing effective treatment starts with an accurate and comprehensive history that defines the older adult's "pain signature" (the parameters affected by pain and the severity of their impact) [22], highlights key comorbidities that contribute to pain or influence its treatment (table 1), identifies treatment targets, and considers the patient’s treatment goals. Older adults may under-report the severity of pain because of misconceptions that pain is a normal part of aging, a tendency toward stoicism [23], or fears of addiction [24]. The coexistence of sensory (eg, vision and/or hearing deficits) and/or cognitive impairment also may make the evaluation of pain more challenging in the older patient.

Determining the patient's pain signature — Identifying each patient's pain signature allows the provider to evaluate response to treatment in a way that is meaningful to the individual [25]. Treatment should prioritize improving function more than reducing pain, thus precisely and comprehensively documenting the impact of pain on function is critical. Answers to the following questions will help to ascertain the older adult's pain signature and, therefore, key treatment outcomes [25,26]:

How strong is your pain (right now, worst/average over past week)?

How many days over the past week have you been unable to do what you would like to do because of your pain?

Over the past week, how often has pain interfered with your ability to take care of yourself, for example with bathing, eating, dressing, and going to the toilet?

Over the past week, how often has pain interfered with your ability to take care of your home-related chores such as going grocery shopping, preparing meals, paying bills, and driving?

How often do you participate in pleasurable activities such as hobbies, socializing with friends, travel? Over the past week, how often has pain interfered with these activities?

How often do you do some type of exercise? Over the past week, how often has pain interfered with your ability to exercise?

Does pain interfere with your ability to think clearly?

Does pain interfere with your appetite? Have you lost weight?

Does pain interfere with your sleep? How often over the past week?

Has pain interfered with your energy, mood, personality, or relationships with other people?

Over the past week, how often have you taken pain medications?

How would you rate your health at the present time? Excellent, good, fair, poor, or bad?

History and review of systems — The past history and review of systems identifies key medical, psychological, and social comorbidities that may contribute to pain and/or impact treatment response (table 1).

Physical examination — The physical examination complements the history by identifying important comorbidities and treatment targets. In addition to assessing standard vital signs (temperature, blood pressure, respiratory rate, pulse), assessment of cognitive function and mobility/balance should be performed in the older adult with chronic pain. Mobility assessment is critical because of the potential impact of pain and some analgesics on falls risk. These evaluations are described in detail separately. (See "Evaluation of cognitive impairment and dementia" and "Falls in older persons: Risk factors and patient evaluation".)

Imaging — Incidental degenerative pathology is common in older adults with and without pain [27-30]; therefore, imaging studies should be restricted to patients in whom a thorough history and physical examination results in high pre-imaging suspicion of a disease that requires specialized intervention (eg, hip pain indicative of possible hip osteoarthritis, neurogenic claudication indicative of possible lumbar spinal stenosis).

Identifying physical contributors to chronic pain — It is important for providers to approach the older adult with any type of chronic pain as an older adult first and a patient with pain second. A basic principle of geriatric medicine is that pathology can make the patient vulnerable to other stressors and these stressors may be the treatment targets, rather than the pathology itself [31]. For example, a patient with low back pain may have degenerative disease of the lumbar spine, but the important treatment target may be co-existent depression.

Four of the most common and misdiagnosed conditions that cause chronic pain in older adults are myofascial pain syndrome, chronic low back pain, lumbar spinal stenosis, and fibromyalgia syndrome. These disorders in the older adult are discussed briefly below, and detailed topics on each entity in the general population are available separately.

Myofascial pain syndrome — Making a timely diagnosis of myofascial pain in the older adult represents a pivotal step toward avoiding unnecessary and potentially harmful diagnostic tests and invasive procedures [32]. (See "Overview of soft tissue musculoskeletal disorders", section on 'Myofascial pain syndrome'.)

Older adults may describe myofascial pain as aching, burning, or stabbing. The pain often radiates a significant distance from the site of the trigger point, mimicking radiculopathy or neuropathic pain. Common myofascial pain syndromes in older adults include piriformis syndrome (compression of the sciatic nerve in the region of the sciatic notch as the nerve comes in close contact with a piriformis muscle that has myofascial dysfunction), upper/lower back pain related to myofascial dysfunction of the paraxial musculature, trapezius myofascial pain, pseudotrochanteric bursitis (tensor fascia lata myofascial dysfunction), and post-herpetic myofascial pain [32,33].

Treatment is three-pronged and consists of:

Identifying and treating the underlying factor(s) that are responsible for creating muscle dysfunction leading to myofascial pain (eg, shoulder dysfunction in the patient with myofascial neck pain, poor sitting posture in the patient with upper back myofascial pain, or an anxiety disorder in the patient with myofascial pain at any site). Identifying potentially offending medications such as statins is especially important in older adults [34]. (See "Statin muscle-related adverse events".)

Deactivating the trigger point with manual therapy, dry needling, or trigger point injection

Building muscle resilience through gentle stretching and strengthening (administered initially by a trained physical therapist or another therapist trained in these techniques, and continued by the patient as part of a home exercise program)

Chronic low back pain — Chronic low back pain (CLBP), like other types of chronic non-cancer pain, is associated with multiple physical and psychosocial factors (see "Evaluation of low back pain in adults", section on 'Initial evaluation'). In a study of 111 community-dwelling older adults with CLBP, over 80 percent had several physical conditions associated with their pain, most commonly myofascial pain, sacroiliac joint syndrome, probable hip osteoarthritis (OA), and/or fibromyalgia syndrome [23]. Our clinical experience suggests that leg length discrepancy following total hip or knee replacement also can precipitate or worsen CLBP. We believe evaluation for these disorders should be performed routinely in older adults with CLBP.

Spinal imaging has poor predictive validity for pain [28,29]. As a general rule in older adults, imaging the spine is often more helpful in demonstrating absence of disease (ie, compression fractures, metastatic bone disease, disk space infection) rather than the cause of pain. However, patients with history or physical examination findings suggestive of fracture, infection, malignancy, or other serious disease should undergo either plain radiographs or advanced imaging, depending on the clinical scenario. (See "Evaluation of low back pain in adults", section on 'Imaging'.)

Older adults commonly have degenerative pathology, much of which has nothing to do with pain. For older adults with CLBP and no clinical findings suggestive of serious disease, imaging should be used judiciously and interpreted cautiously as it is likely to cause undue anxiety over incidental degenerative pathology. Over 95 percent of older adults have degenerative disc and/or facet disease on radiograph [28] and fewer than half report experiencing low back pain during the prior year [35]. Thus, pathology identified on imaging studies may or may not be a contributor to low back pain in the older adult.

We approach the evaluation and treatment of CLBP in older adults as a geriatric syndrome, that is, a final common pathway for the expression of multiple potential contributors [36,37], in which degenerative disease of the lumbosacral spine is a source of vulnerability but not the sole treatment target. We use a set of evidence and expert opinion-based algorithms to guide the evaluation and treatment of common conditions that contribute to pain and disability in older adults with CLBP. The conditions targeted are hip osteoarthritis [38], myofascial pain [39], fibromyalgia [40], depression [41], maladaptive coping [42], lumbar spinal stenosis [43], insomnia [44], lateral hip/thigh pain [45], anxiety [46], sacroiliac joint syndrome [47], dementia [48], and leg length discrepancy [49]. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment" and "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment" and "Exercise therapy for low back pain".)

Lumbar spinal stenosis — Patients with lumbar spinal stenosis often report leg symptoms with prolonged standing or walking (ie, neurogenic claudication); low back pain may or may not be present (see "Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis"). While imaging evidence of spinal stenosis is required prior to surgical intervention, many older adults have spinal stenosis that is asymptomatic. The LAIDBack study found that one in five asymptomatic older adults has moderate to severe central canal stenosis [29].

Treatment should follow a stepped-care approach (see "Lumbar spinal stenosis: Treatment and prognosis"). The surgical failure rate is approximately one in three [50-53]. A prospective cohort study of patients in the Veteran's Administration health system found that only about half of older veterans who undergo decompressive laminectomy experience significant functional improvement, and that pre-operative opioid use, low self-efficacy, and leg length inequality increase the likelihood of failure [54]. Other studies highlight that many conditions common in older adults (eg, hip osteoarthritis, depression, medical comorbidity, osteoporosis) predict poor surgical outcomes [55-59]. It is imperative to thoroughly evaluate the older patient with neurogenic claudication to identify and treat all contributors to pain and disability and ensure the patient has realistic treatment expectations before referring for a surgical consultation. As discussed above, there are many potential contributors to pain and disability in older adults, thus anatomical lumbar spinal stenosis may not be the most important treatment target [31], and treatment outcomes may be suboptimal if only stenosis is treated. In the SPORT investigation, patients who underwent decompressive laminectomy experienced, on average, only 17 percent reduction in back pain and 14 percent reduction in leg pain [60].

Widespread pain — Chronic pain in older adults is often widespread. Generalized osteoarthritis and fibromyalgia are two common causes of widespread pain in this age group. History and physical examination can aid in differential diagnosis of generalized osteoarthritis and fibromyalgia syndrome from other common multifocal pain disorders in older adults [61]. Evaluation and treatment of these disorders in the general population are discussed in detail separately. No randomized trials examining the efficacy of fibromyalgia treatment have been performed exclusively in older adults. (See "Clinical manifestations and diagnosis of fibromyalgia in adults" and "Differential diagnosis of fibromyalgia" and "Treatment of fibromyalgia in adults" and "Overview of the management of osteoarthritis".)

Pain after COVID-19 — A significant portion of patients who develop persistent symptoms after COVID-19 infection (ie, "long COVID") complain of pain, due to changes in the nervous or musculoskeletal systems, disruption in health care, or post intensive care syndrome. These issues are discussed separately. (See "Approach to the management of chronic non-cancer pain in adults", section on 'COVID-19 implications for chronic pain' and "COVID-19: Clinical presentation and diagnosis of adults with persistent symptoms following acute illness ("long COVID")", section on 'Physical symptoms'.)

Treatment goals — The main goal in the treatment of chronic pain is to maximize function (ie, minimize pain interference) and quality of life while minimizing adverse effects that may be associated with treatment. Identifying the impact that the pain has upon all aspects of the patient's life allows the provider to determine treatment targets and evaluate response to treatment in a way that is meaningful to the individual [62].

Due to the multifaceted nature of chronic pain, total pain elimination is not a realistic goal. It is therefore important to ensure that the older patient understands three general principles in the expectations of optimal pain management:

Chronic pain is multifactorial, requiring an approach that addresses the nociceptive input (eg, knee osteoarthritis) and the factors that impact top-down inhibition of pain, such as depression, anxiety, and maladaptive coping. Nonpharmacologic and pharmacologic strategies are needed to approach these issues.

Chronic pain is treatable, with improvement anticipated, but it is not curable (ie., achieving a pain score of 0 is not realistic).

Although pain may not be totally eliminated, substantial improvement in function is realistic [61]

Effective management of chronic pain must consider not only the underlying condition(s) contributing to pain and the factors that impact top-down inhibition of pain but also medical comorbidities, and potential drug-drug and drug-disease interactions that are more prevalent in older adults. Environmental factors: physical, psychosocial, and economic (table 1) also must be considered. General issues with respect to drug prescribing in older adults are discussed in detail separately (see "Drug prescribing for older adults"). Pain management is reviewed below.

Stepped care — A "stepped" approach to the treatment of pain is usually advocated for older adults. (See "Drug prescribing for older adults", section on 'A stepwise approach to prescribing'.)

The least potentially toxic interventions are used initially, followed as needed by therapies associated with greater risks. Systemic medications are generally introduced at a later step than in younger adults, due to the increased potential for side effects, toxicity, and interactions with medications used for chronic illnesses. Consequently, the use of nonpharmacologic treatments, or localized use of medications (eg, corticosteroid injections) may be preferred as initial therapy for many conditions, particularly in patients with multiple chronic conditions and medications. When nonpharmacologic therapy is ineffective, pharmacological treatment should be guided by aging-specific considerations as discussed below. (See 'Nonpharmacologic treatments' below and 'Pharmacologic treatments' below.)

In some cases, surgical treatment of chronic pain (eg, joint replacement, spinal surgery) may be indicated when nonpharmacologic treatment is ineffective and pharmacologic treatment is either ineffective or not tolerated.

NONPHARMACOLOGIC TREATMENTS — Nonpharmacological approaches to the management of chronic pain are often beneficial, in place of or in addition to pharmacological treatments. Nonpharmacologic therapies encompass a wide array of treatments that may be grouped into the physical interventions (including physical therapy, acupuncture, chiropractic manipulation, massage, and others) and the psychoeducational interventions (such as cognitive-behavioral therapy, meditation, and patient education, including pain neuroscience education [63]). Many of these therapies are low cost, with minimal side effects, and may decrease the dose and therefore the risk from any needed medications [64]. Treatments with associated cost or potential side effects should be used only when there is evidence of benefit in patients with similar painful conditions. (See "Approach to the management of chronic non-cancer pain in adults", section on 'Nonpharmacologic therapies'.)

General therapies such as self-management education, physical therapy/exercise, and cognitive behavioral therapy may be used for all chronic pain conditions. Other more specific therapies can be helpful, though indications are unclear, and only limited studies have been performed in older adults [65-77]. A 2018 meta-analysis of 22 small randomized trials that evaluated psychological interventions (ie, cognitive behavioral therapy alone or in combination with other therapies) for older chronic pain patients (mean age 72 years) reported small reductions in pain with treatment, which persisted at six month follow-up [78]. In the studies that evaluated pain medication consumption, there was no reduction in the use of opioids or other pain medication with treatment. Benefits were greatest with group-based rather than individual therapy.

The efficacy of nonpharmacologic treatments does not appear to differ in older adults compared with other ages. The 2017 American College of Physicians (ACP) guidelines for the treatment of acute, subacute, and chronic low back pain recommend nonpharmacological treatments early in the treatment of patients with CLBP [79]. Two of the three studies cited by the ACP guidelines as demonstrating moderate quality evidence for the efficacy of mindfulness meditation were performed specifically in older adults [80,81].

A 2024 systematic review of the literature on nonpharmacologic treatments for neuropathic pain in older adults found 19 small studies with methodologic limitations that precluded definitive conclusions [82]. Results were mixed, with the strongest evidence supporting electrical and/or magnetic stimulation. There were few adverse effects, and it appeared that benefits likely outweigh the risks.

PHARMACOLOGIC TREATMENTS — Patients whose pain causes functional impairment or diminished quality of life despite nonpharmacologic treatments may require pharmacologic therapy. Routes of administration, medications, and doses should be selected that are the least likely to lead to toxicity, side effects, or interactions with other medications. Suggested doses may be found in the table (table 2). (See "Drug prescribing for older adults".)

In most cases, non-opioid medications are preferred to opioids for non-cancer pain, due to side effects in older patients. However, as highlighted in the 2022 Centers for Disease Control (CDC) guideline for prescribing opioids for pain, both opioids and some non-opioids (eg, NSAIDs, tricyclic antidepressants) are associated with important risks in older adults [83]. Thus, the choice of analgesics should be driven by carefully weighing potential risks and benefits as well as patient preferences.

Analgesics should be initiated at the lowest effective dose and titrated to achieve pain control with minimal adverse effects; this requires frequent reassessment of patients for pain relief and side effects as doses are adjusted. Localized use of medication (eg, joint injections, trigger point injections) may be preferable to systemic medications (eg, oral analgesics) when applicable. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'General principles of drug selection'.)

Nonpharmacologic treatments that have improved analgesia should be continued when medications are added, to improve pain control and minimize medication doses.

Non-opioids — The choice of an appropriate initial therapeutic agent is dependent upon an accurate evaluation of the cause of the pain and the type of chronic pain syndrome. In particular, neuropathic pain should be distinguished from nociceptive pain. (See "Evaluation of chronic non-cancer pain in adults", section on 'Pain assessment'.)

The initial treatment of neuropathic pain involves either antidepressants or antiseizure medications, with adjunctive topical therapy when pain is localized (table 2). In contrast, first-line therapy for nociceptive pain is generally acetaminophen or nonsteroidal anti-inflammatory medications (NSAIDs); however, prolonged use of NSAIDS are contraindicated in older adults with chronic pain because of the increased risk of adverse events in this population. (See "Drug prescribing for older adults", section on 'Beers criteria' and "Pharmacologic management of chronic non-cancer pain in adults", section on 'General principles of drug selection'.)

Topical and injected analgesics — Topical analgesics (table 3) have the benefit of avoiding systemic adverse effects, and thus are a good option in the older patient. Injection therapy (eg, joint injections, trigger point injections) may be preferred to systemic medications to decrease toxicity and side effects in older adults; this is in contrast to younger adults, in whom systemic medication is sometimes preferred as a less invasive alternative. The use of injections should be limited to patients with conditions in which there is evidence of efficacy. (See "Management of knee osteoarthritis", section on 'Topical NSAIDs' and "Joint aspiration and injection in adults: Indications and technique" and "Subacute and chronic low back pain: Nonsurgical interventional treatment".)

Acetaminophen — Acetaminophen is the first-line treatment in the management of mild chronic pain in the older adult because of its greater safety compared to other analgesics, particularly nonsteroidal anti-inflammatory drugs (NSAIDs) [21]. However, acetaminophen lacks significant anti-inflammatory properties, making acetaminophen less effective for chronic inflammatory pain than NSAIDs [84].

Patients should be educated on the maximum safe dose due to potential liver toxicity. Acetaminophen is included as a component of many over-the-counter combination medications, and patients may not be aware that they are taking acetaminophen when they are using such products. Thus, total dosing of acetaminophen from all sources needs to be determined, with a specific request that patients bring in all medications, including over-the-counter products, that they take. A maximum acetaminophen dose less than 3 grams in 24 hours is a prudent approach [85], or less than 2 g per day in frail patients, those over 80 years of age, and those who use alcohol on a regular basis (table 2). The American Geriatric Society guideline on management of chronic pain considers <4 grams in 24 hours from all sources acceptable [21]. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Acetaminophen'.)

Notably, patients receiving both acetaminophen and cytochrome P450 inducing drugs (table 4) are at increased risk of liver problems.

Nonsteroidal anti-inflammatory drugs — In general, nonsteroidal anti-inflammatory drugs (NSAIDS) should only be used briefly (eg, one to two weeks) during episodes of increased nociceptive pain [86]. When NSAIDs are needed in older adults, low doses should be used, and the choice of drug tailored to the patient's risk factors for gastrointestinal and cardiovascular disease [87]. Naproxen is a reasonable choice in patients at risk of cardiovascular disease. Patients at risk of gastrointestinal toxicity should have a gastroprotective agent prescribed, and may have a lower risk with use of a nonacetylated salicylate or cyclooxygenase (COX)-2 inhibitor. Reasonable doses are found in the table (table 2). (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Nonsteroidal anti-inflammatory drugs'.)

Although in the general population over-the-counter doses of some NSAIDs (eg, 220 mg naproxen sodium) have a good safety profile [88], risks for adverse effects are significantly higher in the older adult [21], especially those with chronic kidney disease, gastropathy, and cardiovascular disease, or those who may be intravascularly depleted (eg, heart failure) [86]. Gastrointestinal bleeding and peptic ulcer disease occur in approximately 1 percent of patients treated for three to six months, and 2 to 4 percent of patients treated for one year; the use of a proton pump inhibitor or misoprostol reduces but does not eliminate the risk, while use of systemic corticosteroids, anticoagulants, or antiplatelet agents increases the risk. Nonacetylated salicylates (eg, salsalate) may have less gastrointestinal toxicity than other NSAIDS [89,90]. COX-2 selective inhibitors have a lower risk of gastrointestinal side effects [91], but cardiovascular risks are higher. In a 2014 meta-analysis of 280 trials of NSAIDS versus placebo and 474 trials comparing NSAIDs, risk for coronary and vascular events were increased by COX-2 inhibitors, high-dose diclofenac, and possibly ibuprofen, but naproxen did not increase risk [92]. (See "NSAIDs: Adverse cardiovascular effects" and "Nonselective NSAIDs: Overview of adverse effects".)

Antidepressants — Antidepressants used in the treatment of chronic neuropathic pain include tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and selective noradrenalin reuptake inhibitors (SNRIs), all of which have increased side effects in older adults. Reasonable choices are nortriptyline, desipramine, and duloxetine (table 2); the choice for specific patients may be based on the side effect profile of each drug (table 5). (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Antidepressants'.)

TCAs are highly anticholinergic, leading to sedation, cognitive dysfunction, and orthostatic hypotension; anticholinergic effects are most prominent in older TCAs (eg, amitriptyline), with lower prevalence in the secondary amines (eg, nortriptyline, desipramine). All TCAs are, however, included as part of Beers list of potentially inappropriate medications in older adults [93]; an exception is low-dose doxepin (≤6 mg/day), which has a safety profile comparable with placebo [21,86,93]. Drug interactions are also a concern when patients are taking drugs that affect hepatic metabolism, are active within the central nervous system, or have serotonergic, noradrenergic, or anticholinergic effects [94]. Extreme caution must be exercised in older adults with a seizure disorder or who take medicine that can reduce the seizure threshold (ie, tramadol), those with cardiovascular disease, uncontrolled narrow-angle glaucoma, hepatic disease, or at increased risk of falls [94].

SNRIs (eg, duloxetine) may be used in the treatment of chronic neuropathic pain and tend to have fewer cardiovascular and anticholinergic adverse effects than TCAs [94,95].

Efficacy of the types of antidepressants for various types of pain is discussed in detail separately. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Antidepressants'.)

Antiseizure medications — Pregabalin and gabapentin have a better safety profile in older adults than the other antiseizure medications used for chronic pain (table 2) [94]. Pregabalin and gabapentin are effective in the treatment of neuropathic pain [94,96]; the most common side effects are dizziness, somnolence, fatigue, and weight changes [97]. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Antiseizure medications'.)

Between 2003 and 2016, coadministration of gabapentinoids with opioids tripled, as part of a strategy to manage chronic non-cancer pain in the older adult [98]. Concurrent use of these two drug classes increases the risk of central nervous system depression, which can result in both respiratory depression and an increased risk of falls [99] (see "Use of opioids in the management of chronic non-cancer pain", section on 'Drug interactions'). Clinicians should discuss the risk benefit ratio of using both classes of medications with patients and their families or care providers.

Carbamazepine and oxcarbazepine should be avoided due to risks of hyponatremia and syndrome of inappropriate antidiuretic hormone secretion, from which older adults are already at higher risk [94]. For trigeminal neuralgia, carbamazepine (or possibly oxcarbazepine) is the treatment of choice; using the lowest effective dose may decrease the incidence of side effects. (See "Trigeminal neuralgia", section on 'Medical treatment'.)

Muscle relaxants — Muscle relaxants such as baclofen, cyclobenzaprine, and methocarbamol may not be tolerated in older adults due to side effects, including sedation, dizziness, anticholinergic effects, and weakness [100]. They should be avoided for individuals aged 65 and older. (See "Treatment of acute low back pain", section on 'Combination with muscle relaxants'.)

Opioids — The role of opioid therapy in the treatment of chronic pain is discussed elsewhere. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Opioids'.)

When considering the use of opioid medications for the older patient with chronic pain, we agree with the approach of the American Geriatrics Society (AGS) [101]. In the 2019 updated AGS Beers Criteria, newly added drug-drug interactions include the risk of substantial harm that can occur with concurrent use of opioids with benzodiazepines or gabapentinoids [101]. These concerns should be balanced with the need to treat chronic pain. The following issues should be considered:

What is conventional practice for this type of pain or patient?

Is there an alternative therapy that is likely to have an equivalent or better therapeutic index for pain control, functional restoration, and improvement in quality of life?

Does the patient have medical problems that may increase the risk of opioid-related adverse effects?

Is the patient likely to manage the opioid therapy responsibly (or relevant caregiver likely to responsibly co-manage)?

Many older adults are reluctant to use opioids because of concerns about addiction. Education on the difference between dependence, tolerance, and addiction may help patients accept opioids when they are indicated. Because of the lack of high quality evidence, the prevalence of opioid use disorder in older adults is unknown [102]. (See "Opioid use disorder: Epidemiology, clinical features, health consequences, screening, and assessment", section on 'Clinical manifestations'.)

The 2022 CDC guideline for opioid prescribing points out specific issues related to the use of opioids in older adults, including: [83]

Patients should be educated to avoid behaviors that increase risk, such as saving unused opioids

Caregivers play an important role in management of opioid therapy in patients with cognitive impairment

Older adults should be monitored for cognitive impairment and the risk of falls related to opioids

Exercise and bowel regimens should be instituted to prevent constipation

Choice and dosing of opioid — The choice and dose of specific opioid depend upon desired route of administration (eg, oral, sublingual, rectal suppository, transdermal, subcutaneous), onset time, duration of action, interactions with other medications, coexisting medical conditions, and sensitivity to side effects. In general, reasonable choices in older adults include morphine, oxycodone, hydromorphone, fentanyl, and buprenorphine.

The majority of patients with chronic pain will use oral medications. Patients with difficulty swallowing may benefit from medications available in liquid form (eg, hydromorphone, morphine, oxycodone) or as a lozenge (eg, fentanyl). A transdermal patch (eg, fentanyl, buprenorphine) may also be a good alternative for patients who have difficulty swallowing, although absorption from the patch may be compromised in patients with decreased subcutaneous tissue, a potential problem in frail, older adults [103]. As with all long-acting opioids, the patch should be avoided in opioid-naïve patients [104].

Patients with frequent or continuous daily pain benefit from a long-acting medication used on a schedule rather than as needed; this increases dosing intervals and permits steady-state therapeutic drug levels to be maintained. This is also helpful for those with difficulty managing a frequent dosing schedule (eg, cognitive dysfunction, memory impairment, unreliable caregiver). This may be achieved using drugs with long half-lives or controlled-release oral formulations (eg, morphine, oxycodone), or by using a patch (eg, fentanyl, buprenorphine). Patients on long-acting opioids may have episodes of breakthrough pain, for which shorter-acting, immediate-release medications (eg, morphine, oxycodone) should be available.

Doses of opioid medications should be reduced in older adults and titrated slowly to effect, with close monitoring for side effects. We suggest decreasing the initial dose by 25 percent for a 60-year-old patient (by 50 percent for an 80-year-old) from the initial dose that a 40-year-old would normally receive, but at the same intervals (table 2) [105]. Older adults generally have increased pharmacodynamic sensitivity to opioids, but great interindividual dose-response variability can make dosing challenging [105-108].

Morphine has no consistent age-related changes in pharmacokinetics, but due to increased sensitivity initial doses should be reduced. Active metabolites are renally eliminated, so morphine should be avoided in renally-impaired patients (GFR <30 mL/min) [109].

Oxycodone is a good choice in older adults because of a short half-life, no toxic metabolites, and availability in both the short- and long-acting forms [110].

Buprenorphine is a high-affinity partial mu-opioid receptor agonist that can be used safely in renally-impaired patients [111]. It has a ceiling to respiratory depression but not to analgesia over a dose range from 0.05 to 0.6 mg intravenous buprenorphine in healthy adults [112]. The incidence of nausea, vomiting, and constipation are lower than with morphine [113].

Hydromorphone is only available in a short-acting formulation and should be used primarily as a breakthrough medication.

Fentanyl can be used in patients with mild-moderate renal and hepatic dysfunction. It is a short-acting medication (appropriate for breakthrough pain) but is also available as a transdermal patch.

More problematic options in older adults include:

Oxymorphone is a semisynthetic mu-opioid receptor agonist (similar to hydromorphone). As a relatively new opioid, there is not extensive experience in older adults, and it may be more expensive than alternatives.

Methadone acts on the mu-opioid receptor as well as the N-methyl-D-aspartate receptor. Because of its complicated and variable pharmacokinetics and pharmacodynamics, methadone should only be initiated by clinicians who are familiar with its administration. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Choice of agent and dosing for chronic therapy'.)

Codeine is a weak analgesic that is metabolized to morphine. It is associated with more nausea and constipation than other opioids [110], and genetic differences make it ineffective in many patients, particularly those of Asian and African descent [114].

Tramadol is a serotonin-norepinephrine reuptake inhibitor (SNRI) that produces a metabolite ODT (O-desmethyltramadol) which is a weak opioid. ODT has unpredictable pharmacokinetics and several potential serious adverse effects, such as seizures, serotonin syndrome, hypoglycemia, and dependence/addiction [115,116].

In 2021 the Food and Drug Administration of the US (FDA) mandated that the tramadol label must include a warning regarding hyponatremia and hypoglycemia [117]. The warning was prompted by rarely reported cases of severe hyponatremia in patients taking tramadol, most of which occurred in females >65 years of age and within the first week of therapy. There are also reported cases of severe hypoglycemia with tramadol, most in patients with diabetes and in the first 30 days of therapy [118].

Mixed agonist/antagonist drugs (eg, butorphanol and nalbuphine) have a relatively higher rate of side effects compared with other opioids.

Meperidine is avoided due to a toxic metabolite with a long half-life (15 to 30 hours) that can cause neuro-excitation and seizures, and that may cause serotonin syndrome when administered within two weeks of receiving a monoamine oxidase inhibitor [110].

Older adults with chronic kidney disease — There are currently no evidence-based guidelines for older adults with non-dialysis chronic kidney disease (CKD), defined by the Kidney Disease Improving Global Outcomes as estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73m2 for greater than three months [119]. Older adults with decreased renal function may accumulate opioids and associated active metabolites. Opioids with active metabolites that are renally-cleared include codeine, hydromorphone, meperidine, morphine, oxycodone, and tramadol. Morphine, codeine and meperidine in particular, should not be used in patients with CKD [120-122]. Oral hydromorphone, though renally cleared, is the preferred short-acting opioid in this population as it has been shown to be a more tolerable alternative to morphine [121]. Oxycodone is an acceptable short -acting option if monitored very closely. Oral methadone is useful as a longer-acting opioid but should be prescribed in conjunction with a pain specialist due to great fluctuations between individuals pharmacokinetic and pharmacodynamic profiles. Non-renally cleared medications such as transdermal buprenorphine and fentanyl are also recommended options for patients with CKD.

Opioid-related adverse effects — Older adults have increased pharmacodynamic sensitivity to all effects of opioid medication, so adverse effects may occur at lower doses than in younger individuals. Adverse reactions involve the gastrointestinal, central nervous, respiratory, and immune systems. Prevention and management of side effects are discussed in greater detail elsewhere. (See "Prevention and management of side effects in patients receiving opioids for chronic pain".)

For patients with opioid related adverse effects, the benefits of opioids should be assessed and weighed against the risks and downsides of therapy, and opioid tapering or discontinuation considered. Opioid tapering is discussed in detail separately. (See "Opioid tapering for patients with chronic pain", section on 'Indications for opioid taper or discontinuation'.)

Mental status – Opioid therapy can cause somnolence or mental clouding, which typically wanes over a period of days or weeks but may be chronic in some patients. Opioid neurotoxicity can be divided into three groups: the first group lowers the level of consciousness (eg, sedation, drowsiness); the second group affects the thinking process and the ability to react (eg, cognitive impairment, psychomotor impairment, delirium, hallucinations, dreams, and nightmares); and the third group has direct toxic effects on neurons (eg, myoclonus, hyperalgesia, and tolerance) [123]. There is evidence that cognitive function is not affected by low-dose transdermal buprenorphine or oral oxycodone in older hospitalized patients, and has a significant positive effect on quality of life [23,24]. (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Somnolence and mental clouding'.)

Constipation – Constipation is the most common side effect of opioid therapy in older adults, with a median frequency of occurrence of 30 percent in a systematic review of opioid use for chronic noncancer pain in older adults (mean age range 60 to 73 years) [124]. Unlike other side effects, patients do not acclimate to opioid-induced constipation. Constipation can occur with any dose and with any duration of use, thus it is prudent to begin prophylactic laxative therapy when opioid treatment is initiated. Buprenorphine and transdermal fentanyl may be less constipating than other opioids. Naloxegol, a pegylated form of naloxone, was approved in the United States in September 2014 for treatment of opioid-induced constipation in patients with noncancer pain and does not reverse the analgesic effect of opioids [125]. (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Opioid bowel dysfunction'.)

Balance – Use of opioids, particularly in combination with other central nervous system active medications [126], may cause balance dysregulation, and could increase the risk of falls. Observational data suggest that opioids in isolation may not be associated with increased risk of falls [127]. Nonetheless, before prescribing opioids, it is important to evaluate the patient’s gait and balance and to educate them about the risk of falls.(See "Falls in older persons: Risk factors and patient evaluation", section on 'Falls risk assessment'.)

If there is evidence of balance impairment, opioids should be prescribed only if the need is pressing and if the patient is referred to physical therapy and/or provided with mobility aids before the patient begins taking the medication. As pain itself places the older adult at risk of falls [7], the healthcare provider also must carefully consider the risk of suboptimal pain treatment.

Respiratory – The normal ventilatory response of the central nervous system to hypercapnia and hypoxemia is diminished with age, and may lead to an exaggerated respiratory depressant effect of opioids (see "Anesthesia for the older adult", section on 'Respiratory system'). However, respiratory depression is rare with low starting doses and appropriate dose titration. Tolerance to the respiratory depressant effects of opioids develops quickly [21].

Opioids also can be associated with sleep-disordered breathing and sleep apnea [128]. The aging process is associated with deterioration of sleep architecture, and patients should be monitored for signs of additional sleep problems (eg, daytime somnolence) following initiation or dose increases in opioids. (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Sleep-disordered breathing'.)

Other gastrointestinal issues – Dry mouth and nausea are also common side effects of opioids [129]. Persistent nausea can often be prevented by gradual upward titration of the opioid dose.

Immune system – Although opioids have immunosuppressive properties, the clinical impact of opioid-induced immunomodulation is unknown.

Cannabis and cannabinoids — Cannabis and cannabinoids are increasingly available, but their efficacy and safety profile in older adults is uncertain. In the general population, limited evidence suggests that cannabis may alleviate neuropathic pain but is associated with an increased risk for motor vehicle accidents, psychotic symptoms, and cognitive impairment [130]. Several aging-related phenomena suggest the possibility of increased risks of cannabis-associated adverse effects in older adults. Such phenomena include reduced hepatic clearance, increased body fat, and changes in the endocannabinoid system including altered cannabinoid receptor sensitivity [131,132].

As noted above, chronic pain itself can have multiple deleterious effects (see 'Effects of chronic pain in older patients' above). Research is required to ascertain the relative risks and benefits of cannabis compared with other pain treatments and with the risks associated with chronic pain itself.

The use of cannabis and cannabinoids for treatment of chronic non-cancer pain is discussed separately. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Cannabis and cannabinoids'.)

CONSIDERATIONS FOR PATIENTS WITH DEMENTIA

Patients able to verbally communicate pain — An overview of the evaluation and management of chronic pain in patients with dementia who are able to report pain is shown in an algorithm (algorithm 1).

Evaluation — Older adults with mild to moderate dementia may be able to report pain reliably [133]. Because chronic non-cancer pain can be reduced but not eliminated, ongoing pain reporting is normal. The practitioner must determine whether pain reporting represents:

Pain-related suffering, or

Pain perseveration (ie, repetitive unemotional reporting of pain [48]), which is common in dementia, or

A proxy for another unmet need (eg, fear of something that the patient is unable to articulate so instead (s)he verbalizes pain) [48,134]

Real-time observation of the older adult with dementia can provide very useful information. For example, if the patient reports that (s)he is unable to walk because (s)he is in too much pain, say to the patient, "Will you take a walk with me now?" then observe the patient walking as you distract him/her with conversation. You may want to hold the patient's hand or provide a wheeled walker. If no difficulty is observed, then lack of confidence in mobility or fear related to dementia may be the source, rather than pain.

Treatment — If the clinician determines that pain reporting is pain perseveration, distraction may be helpful. That is, the clinician may want to redirect the patient by helping them to focus on a stimulus other than their pain (eg, taking a walk, engaging in another enjoyable activity). In addition, it is important to avoid asking the patient about pain unless there are outward signs that indicate pain-related suffering, such as the patient not eating or sleeping because of pain, or visible signs of pain such as grimacing when trying to perform an activity. If pain is associated with suffering, it should be treated effectively. There is a relative dearth of rigorous scientific data on pain management in older adults with dementia. Therefore, if pharmacologic intervention is deemed appropriate, practitioners must rely on pragmatic recommendations:

Prescribe a trial of scheduled analgesics.

Use a stepped-care approach to analgesic prescribing. (See 'Stepped care' above.)

Start low, go slowly, but use enough.

Monitor the patient carefully to balance risks and benefits of pain treatment versus the risks associated with chronic pain itself.

There is increasing evidence that dementia may have an impact on pain perception and treatment expectation. Neuropathological changes in dementia may lead to altered pain perception and response to analgesic medications [135]. As treatment expectation interacts with analgesic pharmacodynamics, those with dementia and reduced treatment expectation may experience a less robust response to analgesics than those who are cognitively intact [136,137]. A variety of treatment approaches have been suggested in the nursing home population where there is a much higher proportion of patients with dementia [138]; however, high-quality studies of the effectiveness of these treatment approaches are limited.

Persistent pain is undertreated in nursing facilities, especially in those patients with cognitive impairment [139,140]. Recognizing the importance of adequate pain control and reduction of analgesic-associated adverse drug reactions, there has been a shift among nursing homes to administer regularly scheduled rather than analgesics on request and to use acetaminophen more than nonsteroidal anti-inflammatory drugs [138].

Pain control in community-dwelling older adults with dementia and no caregiver can be challenging because of the increased risk of noncompliance and challenges in monitoring for adverse effects. When opioids are indicated in these individuals, long-acting preparations that can be administered once or twice daily, or every two to three days may improve compliance [141], but should never be prescribed in opioid-naïve individuals. Arrangements should always be made for an objective observer, such as a home health worker, to monitor for potential adverse effects.

Patients unable to verbally communicate pain — Evaluation and treatment often occur simultaneously in the older adult with advanced dementia. An overview of the evaluation and management of chronic pain in these patients is shown in an algorithm (algorithm 2).

Evaluation — For older adults with more advanced dementia who are unable to verbally communicate about their pain, providers must rely upon caregiver reports and observational scales [142]. The American Geriatrics Society (AGS) encourages the integration of the following six behavioral domains when performing a pain assessment in a cognitively-impaired older adult [2]:

Facial expressions

Verbalizations/vocalizations

Body movements

Changes in interpersonal interactions

Changes in activity patterns/routines

Mental status changes

A number of tools have been developed to assess pain in older adults with advanced dementia; none have been proven to be superior to another [143]. A table summarizes several formal tools that may be utilized by nursing staff to assess pain in this challenging population. These tools are listed in order of length of time to administer (table 6).

Checklist of Nonverbal Pain Indicators (CNPI) [144]

Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) [145]

Pain Assessment in Advanced Dementia (PAINAD) [146]

Mobilization-Observation-Behaviour-Intensity-Dementia-2 Pain Scale (MOBID-2) [147,148]

Pain Assessment for the Dementing Elderly scale (PADE) [149]

Non-Communicative Patients' Pain Assessment Instrument (NOPPAIN) [150]

The PAINAD is used commonly. The patient is observed for three to five minutes during an activity to note breathing, negative vocalizations, facial expressions, body language, and consolability. Each domain is scored from 0 to 2 with a total possible score of 0 to 10 [151]. The PACSLAC consists of a checklist with a total of 60 items and covers the six behavioral domains listed above [143]. The MOBID-2, intended for patients with moderate to advanced dementia, is the only behavioral pain scale that has demonstrated sensitivity to change with pain treatment [148,152].

Treatment — As with the communicative patient, if pharmacological intervention is deemed appropriate, prescribing should be approached pragmatically:

Prescribe a trial of scheduled analgesics.

Use a stepped-care approach to analgesic prescribing. (See 'Stepped care' above.)

Start low, go slowly, but use enough.

Monitor the patient carefully to balance risks and benefits of pain treatment versus the risks associated with persistent pain itself. Adequate pain control may be observed as improvements in behavior and function [153].

Several studies have suggested that aggressive pain management may improve care of this vulnerable patient population, though long term benefits are unclear.

A randomized, double-blind, placebo-controlled, crossover trial demonstrated that social interactions and well-being (measured by the Dementia Care Mapping) were improved in nursing home residents with moderate-to-severe dementia with the administration of acetaminophen 3 g/day during a four-week period, with no effect on agitation [154].

In another trial, nursing home residents with moderate-to-severe dementia were randomly assigned to receive a four-step pain management regimen over 12 weeks or usual care [13]. The experimental intervention group had both lower agitation and pain scores at 8 weeks; however, at week 12 (4 weeks post treatment), agitation did not differ between the two groups.

One prospective observational study including opioid naïve nursing home residents with mild to moderate cognitive impairment and chronic pain reported that administration of low dose oral prolonged release oxycodone/naloxone improved pain with a favorable safety and tolerability profile [155].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic pain management".)

SUMMARY AND RECOMMENDATIONS

Definition – Persistent pain can be defined as pain that continues beyond the expected time of healing, or greater than three to six months.

Taking a comprehensive pain history – Prescribing effective treatment starts with an accurate and comprehensive history that 1) defines the older adult's "pain signature" (the parameters affected by pain and the severity of their impact), 2) highlights key comorbidities that contribute to pain or influence its treatment (table 1), 3) identifies treatment targets, and 4)defines patient goals and preferences. The main goal in the treatment of persistent pain is to maximize function and quality of life while minimizing adverse effects that may be associated with treatment. Identifying each patient's pain signature allows the provider to evaluate response to treatment in a way that is meaningful to the individual. (See 'General approach' above.)

Commonly misdiagnosed pain conditions – Four of the most common and misdiagnosed conditions that cause persistent pain in older adults are myofascial pain syndrome, chronic low back pain, lumbar spinal stenosis, and fibromyalgia syndrome. (See 'Identifying physical contributors to chronic pain' above.)

Avoiding treatment toxicity

A "stepped," approach to the treatment of pain is advocated for older adults. The least potentially toxic interventions are used initially, followed as needed by therapies associated with greater risks. Nonpharmacologic therapies should be used initially whenever possible, and in combination with pharmacologic interventions to minimize the risk of adverse effects. (See 'Nonpharmacologic treatments' above.)

Pharmacologic interventions have increased risk of toxicity because of potential drug-drug and drug-disease interactions as well as aging-associated vulnerabilities. (See 'Stepped care' above.)

Pharmacologic therapy should begin with the routes of administration, medications, and doses which are the least likely to lead to toxicity, side effects, or interactions with other medications (table 2). Localized use of medication (eg, joint or spinal injections, trigger point injections, topical analgesics (table 3)) may be preferable to systemic medications (eg, oral analgesics) when applicable. In most cases a non-opioid medication is the initial choice. (See 'Pharmacologic treatments' above and 'Non-opioids' above.)

Approach to the use of opioids – Doses of opioid medications should be reduced in older adults and titrated slowly to effect, with close monitoring for side effects. We suggest decreasing the initial dose by 25 percent for a 60-year-old patient (by 50 percent for an 80-year-old) from the initial dose that a 40-year-old would normally receive, but at the same intervals (Grade 2C). Opioids with short half-lives and without active or toxic metabolites are preferred. (See 'Opioids' above.)

Patients with dementia

Mild to moderate dementia – Patients with mild to moderate dementia can often reliably report pain (algorithm 1). Before treating it, the healthcare provider must validate that it is associated with suffering, and not simply perseveration or the expression of distress related to another unmet need. (See 'Considerations for patients with dementia' above.)

Advanced dementia – Patients with advanced dementia may be unable to communicate the need for analgesic medications (algorithm 2). In such cases, an empiric analgesic trial accompanied by careful documentation of outcomes (eg, decreased agitation) may be warranted. (See 'Considerations for patients with dementia' above.)

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Topic 16525 Version 39.0

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