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Guidance on the management of pain in older people

  • In this guideline, older people are those 65 years of age and over

Communication

  • Assessment of pain information should be multidimensional and include eliciting pain treatment information as well as location and sensory aspects of pain information. There is a need to further evaluate assessment tools that can specifically assess these aspects of communication (see assessment guidelines: www.britishpainsociety.org/static/uploads/resources/files/book_pain_older_people.pdf)
  • More pain information is elicited by the use of open-ended rather than closed-ended questions, which is a consideration in any form of pain communication assessment and has implications for the assessment and the use of pain assessment instruments
  • Health professionals should not interrupt when patients are conveying pain information, as this disrupts the amount and nature of pain information conveyed
  • Information regarding prognosis is considered important by older adults with chronic musculoskeletal pain, but this is reported to be provided in only about one-third of general practice consultations

Pharmacology

Paracetamol

  • Paracetamol should be considered as first-line treatment for the management of both acute and persistent pain in older people, particularly of musculoskeletal origin, due to demonstrated efficacy and good safety profile
  • There are relatively few cautions and absolute contraindications to prescribing paracetamol
  • It is important that the maximum daily dose (4 g/24 h) is not exceeded

Non-steroidal anti-inflammatory drugs

  • Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase-2 (COX-2) inhibitors should be used with caution in older people after other safer treatments have not provided sufficient pain relief
  • The lowest dose should be used for the shortest duration
  • For older people, an NSAID or selective COX-2 inhibitor should be co-prescribed with a proton-pump inhibitor, choosing the one with the lowest acquisition cost
  • All older people taking NSAIDs or COX-2 inhibitors should be routinely monitored for gastrointestinal, renal, and cardiovascular side effects, and drug–drug and drug–disease interactions

Opioids

  • Opioids have demonstrated efficacy in the short term for both cancer and non-cancer pains, but long-term data are lacking
  • Patients with moderate and severe pain should be considered for opioid therapy, particularly if pain is causing functional impairment or reducing quality of life
  • Patients with continuous pain should be treated with modified-release oral, or transdermal opioid formulations aimed at providing relatively constant plasma concentrations
  • As there is marked variability in how individual patients respond to opioids, treatment must be individualised and carefully monitored for efficacy and tolerability
  • Opioid side-effects (including nausea and vomiting) should be anticipated and suitable prophylaxis considered
  • Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people prescribed opioid therapy
  • Regular patient review is required to assess the therapeutic benefit and to monitor adverse effects

Adjuvant drugs

  • Tricyclic antidepressants have demonstrated efficacy in several types of neuropathic pain. Adverse effects and contraindications limit the use of tricyclic antidepressants in older people
  • Duloxetine has been shown to be effective for the treatment of neuropathic pain and some studies suggest efficacy for non-neuropathic pain such as osteoarthritis and low back pain
  • Other antidepressants (e.g. selective serotonin reuptake inhibitors) have very limited evidence of analgesic efficacy and should not be used as analgesics
  • The lowest dose should be initiated and the dose increased slowly as tolerated
  • Regular patient review is required to assess therapeutic benefit and to monitor adverse effects

Topical therapies

  • Topical NSAIDs may provide an alternative to oral NSAIDs, particularly if pain is localised

Interventional therapies

  • There is a place for the use of interventions for the management of pain across the lifespan. Referral to secondary care or pain clinics are often appropriate to obtain assessment regarding the use of such interventions. In terms of the older population, the evidence is generally weak, mixed, or even lacking on many of the invasive procedures
  • There are a few procedures on which the evidence is a little stronger including:
    • intra-articular corticosteroid injections for knee pain
    • local anaesthetic and steroid injections for herpes zoster
    • spinal nerve blocks for degenerative lumbar disease and spinal stenosis
  • There is limited evidence to support epidural steroid injections for spinal stenosis in older patients but the evidence is not strong for its use in radicular pain or sciatica
  • There is weak evidence to support consideration of sympathectomy for neuropathic pain in the older population
  • Intra-articular (IA) corticosteroid injections in osteoarthritis of the knee are effective in relieving pain in the short term with little risk of complications and/or joint damage. IA hyaluronic acid (HA) is effective and relatively free of systemic adverse effects. It should be considered in patients intolerant to systemic therapy. IA HA appears to have a slower onset of action than IA corticosteroids, but the effects seem to last longer
  • The evidence suggests that microvascular decompression is the treatment of choice for trigeminal neuralgia in healthy patients and percutaneous procedures are indicated for elderly patients with high comorbidity. There is some evidence to support stereotatic radiosurgery

Management of pain in older adults (people over 65 years of age)*

Management of pain in older adults

Psychological interventions

  • Older people with chronic pain may benefit from cognitive behavioural therapy pain management interventions
  • Guided imagery may useful for patients following joint replacement surgery
  • There is limited evidence that biofeedback training and relaxation can be a useful approach for some groups of older adults with chronic pain

Self-management of pain

  • A range of self-management techniques and practices should be considered as an option to be carried out in conjunction with other methods of pain management
  • Arthritis self-management/chronic disease self-management programmes and close derivatives, such as the Expert Patient Programme (www.expertpatients.co.uk), delivered in isolation, without on-going support, cannot yet be recommended to decrease pain and increase function
  • Self-management programmes with mechanisms for longer-term support/maintenance may have a benefit
  • Increasing activity by way of exercise should be considered
  • Exercise should involve strengthening, flexibility, endurance, and balance
  • The preference of the person for the type of exercise should be given serious consideration
  • Motivation and barriers to exercise and activity should be discussed and planned for
  • Exercise should be customised to the individual capacity and needs of the person
  • Maintenance of productive activity and/or exercise should be facilitated
  • There is some evidence that assistive devices may:
    • support community living
    • reduce functional decline
    • reduce care costs
    • reduce pain intensity relative to older people not provided with devices

Complementary therapies

  • There is limited evidence to support the use of complementary therapies with older adults. What evidence does exist is generally weak and based upon small-scale studies without proper use of controls or randomisation procedures

full guidelines available from…

Abdulla A, Adams N, Bone M et al. Guidance on the management of pain in older people.Age and ageing 2013;42: i1–i57. March 2013.
First included: October 13.