Abstract
Chronic pain is a common, long-standing and bitter experience affecting a huge percentage of the still increasing elderly population. Owing to the multifactorial etiopathology and complex clinical presentation with a lot of severe consequences, management of the permanent pain should be varied and tailored to the particular patient. This approach comprises multimodal pharmacotherapy, including all analgesics and adjuvants, likewise selected interventions, physical therapy and rehabilitation, as well psychological counselling.
Key words: elderly, chronic pain, neuropathic pain, multimodal pain treatment, opioids
Introduction
Pain is defined as both sensory and emotionally feeling connected with current or potential tissue damage.1 Persistent pain means pain that continues beyond the expected time of healing, or for minimum 3–6 months.2 Patophysiologically, chronic pain is categorized as nociceptive (from tissue injury), neuropathic (from nerve injury, like in diabetes) or nociplastic (from a sensitized nervous system, like in fibromyalgia).2, 3
As the population of elderly people grows, the number of the oldest, frailest and pain-ridden is increasing at the fastest rate. Numerous comorbidities, as well as psychological, social and environmental factors may contribute to pain severity and effectiveness of treatment applied.
Clinical presentation
In the Polish study PolSenior 2, the incidence of pain was reported by 52% of women and 41% of men aged ≥60 years. Chronic pain was reported in 47.6% of the examined seniors. Of the 4.5 million older people with pain, 25% suffer from severe pain. Chronic pain management with medication was reported by 38% of Polish seniors.4
The most common pain complaints in the elderly are related to osteoarthritis, neurodegenerative and musculoskeletal conditions, peripheral vascular diseases, rheumatoid arthritis, polymyalgia rheumatica, giant cell angiitis, as well to often misdiagnosed myofascial pain syndrome, low back pain, lumbar spinal stenosis, and fibromyalgia.1, 2, 3, 5
Interestingly, older people manifest an altered pain experiencing, which is a result of the changed pain processing mechanisms involving a structural and functional brain plasticity. This phenomenon is probably associated with the degeneration of circuits modulating the descending pain inhibitory pathways, with the periaqueductal gray (PAG) constituting a key node.6
Prolonged pain may impair physical and cognitive functions manifested by falls, kinesiophobia, immobility, problems with appetite and sleep, depression, anxiety, and increased risk of dementia and delirium.1, 2, 3, 5
It should be emphasized that there are bidirectional interrelations among pain and depression, insomnia and anxiety. Finally, permanent pain can contribute to worsened life quality, social isolation, impaired physical activity, and institutionalization.
Management of chronic pain
Currently, the importance of a multidisciplinary model of pain treatment is emphasized strongly. This approach comprises multimodal pharmacotherapy, selected interventions, physical therapy and rehabilitation, as well psychological counselling. Cuomo et al. proposed the “multimodal trolley approach” that takes into account the physical, psychological and emotional causes of pain and underlies the necessity for personalized therapy. According to this approach, a dynamic management of pain by combining several pharmacologic and non-pharmacologic strategies is possible.7
The principles of the analgesic ladder (as outlined by the World Health Organization (WHO) in 2019) should be followed when introducing analgesics. The 1st step for mild pain is acetaminophen, metamizole or nonsteroidal anti-inflammatory drugs (NSAIDs). For moderate pain, it is recommended to use weak opioids such as tramadol, codeine or dihydrocodone. For severe and persistent pain, the 3rd step involves potent opioids (morphine, buprenorphine, oxycodone, tapentadol, fentanyl).8, 9, 10 It is important to note that many older adults are reluctant to use opioids due to concerns about addiction. However, proper education can help them accept opioids when medically necessary.
Because of the complex nature of pain perception, there is a wide range of drugs from different classes that can be beneficial in different pain conditions. These so-called adjuvants or co-analgesics include antidepressants: tricyclic antidepressants (amitriptyline, nortriptyline), serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine), anticonvulsants (pregabalin, gabapentin), topical agents (lidocaine or capsaicin patches), corticosteroids, bisphosphonates, miorelaxants and also medicinal cannabinoids. Interestingly, although adjuvants are co-administered with analgesics, they are indicated as a first-line treatment option for treating specific pain conditions, like neuropathic pain and fibromyalgia.6, 8, 9, 10
It is important to emphasize that there is a generally accepted gold standard for pharmacotherapy in geriatric patients that should always be followed: “Start low and go slow”.