Management of persistent pain in the older patient: A clinical review

Una E. Makris, Robert C. Abrams, Barry Gurland, M. Carrington Reid

Research output: Contribution to journalArticle

105 Citations (Scopus)

Abstract

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. This review is relevant for physicians who seek an age-appropriate approach to delivering pain care for the older adult. EVIDENCE ACQUISITION: Search of MEDLINE and the Cochrane database from January 1990 through May 2014, using the search terms older adults, senior, ages 65 and above, elderly, and aged along with non-cancer pain, chronic pain, persistent pain, pain management, intractable pain, and refractory pain to identify English-language peer-reviewed systematic reviews, meta-analyses, Cochrane reviews, consensus statements, and guidelines relevant to the management of persistent pain in older adults. FINDINGS: Of the 92 identified studies, 35 evaluated pharmacologic interventions, whereas 57 examined nonpharmacologic modalities; the majority (n = 50) focused on older adults with osteoarthritis. This evidence base supports a stepwise approach with acetaminophen as first-line therapy. If treatment goals are not met, a trial of a topical nonsteroidal anti-inflammatory drug, tramadol, or both is recommended. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. Careful surveillance to monitor for toxicity and efficacy is critical, given that advancing age increases risk for adverse effects. A multimodal approach is strongly recommended - emphasizing a combination of both pharmacologic and nonpharmacologic treatments to include physical and occupational rehabilitation, as well as cognitive-behavioral and movement-based interventions. An integrated pain management approach is ideally achieved by cultivating a strong therapeutic alliance between the older patient and the physician. CONCLUSIONS AND RELEVANCE: Treatment planning for persistent pain in later life requires a clear understanding of the patient's treatment goals and expectations, comorbidities, and cognitive and functional status, as well as coordinating community resources and family support when available. A combination of pharmacologic, nonpharmacologic, and rehabilitative approaches in addition to a strong therapeutic alliance between the patient and physician is essential in setting, adjusting, and achieving realistic goals of therapy.

Original languageEnglish (US)
Pages (from-to)825-836
Number of pages12
JournalJAMA - Journal of the American Medical Association
Volume312
Issue number8
DOIs
StatePublished - Aug 27 2014

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Pain Management
Pain
Intractable Pain
Therapeutics
Physicians
Anti-Inflammatory Agents
Physician-Patient Relations
Tramadol
Acetaminophen
MEDLINE
Chronic Pain
Osteoarthritis
Pharmaceutical Preparations
Meta-Analysis
Comorbidity
Consensus
Language
Rehabilitation
Databases
Guidelines

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Management of persistent pain in the older patient : A clinical review. / Makris, Una E.; Abrams, Robert C.; Gurland, Barry; Reid, M. Carrington.

In: JAMA - Journal of the American Medical Association, Vol. 312, No. 8, 27.08.2014, p. 825-836.

Research output: Contribution to journalArticle

Makris, Una E. ; Abrams, Robert C. ; Gurland, Barry ; Reid, M. Carrington. / Management of persistent pain in the older patient : A clinical review. In: JAMA - Journal of the American Medical Association. 2014 ; Vol. 312, No. 8. pp. 825-836.
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