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JAMA. 2014 Aug 27;312(8):825-36. doi: 10.1001/jama.2014.9405.

Management of persistent pain in the older patient: a clinical review.

Author information

1
Department of Internal Medicine, Division of Rheumatic Diseases, UT Southwestern Medical Center, Dallas, Texas2Department of Medicine, Division of Rheumatology, Veterans Administration Medical Center, Dallas, Texas.
2
Department of Psychiatry, Weill Cornell Medical College, New York, New York4Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York.
3
Stroud Center, Columbia University, New York, New York.
4
Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York.

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 (nā€‰=ā€‰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.

PMID:
25157726
PMCID:
PMC4372897
DOI:
10.1001/jama.2014.9405
[Indexed for MEDLINE]
Free PMC Article

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