Persistent Pain in Older Patients: Best Practices
the MPR take:
Persistent pain in later life is prevalent, costly, and often disabling to patients. A new review in the Journal of the American Medical Association identified 92 studies (35 pharmacologic, 57 nonpharmacologic) on interventions to improve treatment outcomes in this population. Although inferior to oral NSAIDs for pain reduction and stiffness, acetaminophen is recommended as a first-line therapy. A trial of a topical NSAIDs (particularly if pain is localized), tramadol, or both is recommended if treatment goals are not met. For long-term use, oral NSAIDs are not recommended given the risks associated with these drugs (GI bleeding, renal, cardiovascular toxicity). For patients suffering with moderate to severe pain or in those whose lives are severely impacted by pain and who have failed other therapies, opioids may be considered. Anticonvulsants such as pregabalin and gabapentin are recommended for older patients with neuropathic pain, however, tertiary tricyclics (eg, amitriptyline, doxepin) should be avoided because of the potential for adverse effects (anticholinergic, noradrenergic). A combination of pharmacologic and nonpharmacologic treatments such as physical and occupational rehabilitation, cognitive-behavioral and movement-based interventions are strongly recommended for optimal treatment outcomes. Most of all, physicians and patients should be allied in setting realistic therapeutic goals for pain management.
Importance: Persistent pain is highly prevalent, costly, and frequently disabling in later life. Objective: To describe barriers to the management of persistent pain among older adults, summarize current management approaches, including pharmacologic and nonpharmacologic modalities; present rehabilitative approaches; and highlight aspects of the patient-physician relationship that can help to improve treatment outcomes.
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