The bottom line
Chronic pain in later life is a worldwide problem
All older adults with chronic pain should undergo a comprehensive geriatric pain assessment
A comprehensive assessment can guide selection of treatments most likely to benefit
the patient and identify targets for intervention besides pain relief
A multimodal approach that includes both drug and non-drug modalities for pain is
Given the limited reach of cognitive behavioral and exercise approaches to manage
pain in later life, patients should be encouraged to engage in and adopt these techniques
Involve and engage family members and paid caregivers and seek out other resources
that can help to reinforce adherence to treatment and maintain gains from treatment
Chronic pain is one of the most common conditions encountered by healthcare professionals,
particularly among older (≥65 years) patients.1 Pain is associated with substantial
disability from reduced mobility, avoidance of activity, falls, depression and anxiety,
sleep impairment, and isolation.1
3 Its negative effects extend beyond the patient, to disrupt both family and social
relationships. Chronic pain poses a significant economic burden on society.1 Prevalence
rates for pain are expected to increase as populations continue to age—by 2035 an
estimated one quarter of the population in the European Union will be 65 or older—thereby
increasing the public health impact of pain. Healthcare providers, irrespective of
specialty, should develop competencies to assess and manage chronic pain in their
older patients. In this review we summarize recent evidence on the assessment and
management of pain in older patients. Evidence is taken from systematic reviews, meta-analyses,
individual trials, and clinical guidelines.
Sources and selection criteria
We searched Medline, Embase, and the Cochrane Database of Systematic Reviews using
the search terms “chronic pain”, “older adults”, “prevalence”, “diagnosis”, and “treatment”.
We specifically focused on identifying and reviewing systematic reviews, meta-analyses,
high quality randomized controlled trials, and clinical guidelines published during
the past five years whenever possible.
What is chronic pain and how is it caused?
Although no universally accepted definition exists for chronic pain, it is often defined
as pain that persists beyond the expected time of healing (typically 12 weeks) and
may or may not be associated with an identifiable cause or actual tissue damage.3
4 Musculoskeletal disorders are common in later life, and increasingly common are
painful neuropathies from diabetes, herpes zoster, chemotherapy, and surgery. Other
types of pain are also prevalent among older adults, including pain due to cancer
as well as cancer treatments.5
6 Pain is also common in the advanced stages of many chronic diseases, including congestive
heart failure, end stage renal disease, and chronic obstructive pulmonary disease.7
Furthermore, millions of joint repair and replacement surgeries are performed annually,
and an important minority of patients undergoing these procedures report chronic pain
despite surgery.8 Finally, vertebral compression fractures are highly prevalent and
cause substantial pain and discomfort, particularly among older women.9 Box 1 lists
other common diseases where pain is a major symptom.
Box 1 Diseases associated with chronic pain in later life, by system or specialty
Dermatology—pressure or ischemic ulcers, burns, scleroderma
Gastrointestinal—constipation, irritable bowel disease, diverticulitis, inflammatory
Cardiovascular—advanced heart disease, peripheral vascular disease
Pulmonary—advanced chronic obstructive pulmonary disease, pleurisy
Rheumatology—osteoarthritis, rheumatoid arthritis, gout, pseudogout, polymyalgia rheumatica,
spinal stenosis and other low back syndromes, myofascial syndromes, osteoporotic related
Endocrine—diabetic neuropathy, Paget’s disease
Nephrology—chronic cystitis, end stage renal disease
Immune—herpes zoster, post-herpetic neuralgia, HIV/AIDs neuropathy
Neurology—headache, peripheral neuropathies, compressive neuropathies, radiculopathies,
Parkinson’s disease, post-stroke pain
Miscellaneous—depression, tendonitis, bursitis
Who gets it?
Chronic pain in later life is a worldwide problem. In one nationwide survey of older
adults (n=7601) in the United States, 52.8% reported experiencing bothersome pain
in the preceding month.10 Similar findings have been reported in studies conducted
in Europe, Asia, and Australia11
13 and in both developed and less developed countries.14 Risk factors include advancing
age, female sex, lower socioeconomic status, lower educational level, obesity, tobacco
use, history of injury, history of a physically strenuous job, childhood trauma, and
depression or anxiety.
Factors predicting poor outcomes (that is, higher pain scores, disability, depression)
among people with chronic pain include higher levels of pain severity and disability,
longer duration of pain, multiple pain sites, history of anxiety or depression, maladaptive
coping strategies (for example, worry, avoidance), and low social support at the time
of diagnosis. In one study of older adults (n=403) with musculoskeletal pain, three
brief items assessed at the initial clinical encounter—degree of interference from
pain, pain in multiple body sites, and duration of pain—predicted lack of patient
improvement at six months and helped general practitioners predict this outcome above
clinical judgment alone.15 Simple risk stratification approaches like this could help
to tailor care.
How are older patients with chronic pain assessed?
A comprehensive pain assessment can increase the likelihood of identifying a specific
diagnosis for the pain, guide selection of treatments most likely to benefit the patient,
and identify targets for intervention (for example, unrealistic treatment goals) besides
pain relief. Office based assessment can be challenging, however, because of constraints
on time. Having patients complete parts of the assessment before the visit (or in
the office over multiple visits) can be helpful.
Clinicians often struggle with the question of how comprehensive the assessment needs
to be to establish a specific cause of pain. Unfortunately the literature provides
little guidance on this but does indicate that a specific cause is not found in a
large number of patients, despite comprehensive evaluation. Potential benefits to
identifying a cause of pain include earlier initiation of an appropriate treatment
and providing reassurance as patients often worry about the cause of their pain. These
putative benefits must be weighed against the risks of extensive investigations, which
often uncover incidental findings, are expensive, and can increase patient worry.
Chronic pain is more than just a sensory event; it has affective (emotional responses
to pain), cognitive (attitudes and beliefs about pain), behavioral (for example, behaviors
manifested in response to pain by patients and their family members or caregivers),
as well as sensory components (for example, quality, location, temporal pattern).
Assessing for the presence and severity of pain captures only a small part of the
pain experience. All older patients with chronic pain should undergo a comprehensive
pain assessment (box 2 outlines the key elements).
Box 2 Key elements of a comprehensive pain assessment
Administering standardized pain assessment tools—this can provide additional information
above and beyond what is generated by the interview and physical examination. Table
1 includes measures that are for the most part simple, brief, and appropriate for
being self administered. The brief pain inventory-short form and the geriatric pain
measure are recommended for routine use in practice because they are easy to complete,
have been successfully used in studies of older adults, and assess multiple salient
dimensions of the pain experience. It is important to employ assessments that older
patients can do without difficulty and to use the same tools at each visit to assess
for change in a given outcome over time
Ascertaining the impact of chronic pain on functioning—for example, activities of
daily living, social functioning, sleep
Identifying attitudes and beliefs about pain, as well as treatment goals and expectations—many
older patients endorse beliefs that operate as important barriers to engagement with
and adherence to treatment. Older patients’ goals may or may not be the same as the
healthcare provider’s goals. In addition, patients may have unrealistic (for example,
expect complete pain relief) or negative (for example, treatments will not help) expectations
that can serve as targets for intervention16
Gathering data from family members and paid caregivers—gathering information from
third parties about an older patient’s response to pain and the impact it has at home
may be essential, particularly when patients cannot provide this information because
of difficulties with communication as a consequence of stroke or advanced dementia
Identifying resources to include family members, other caregivers, and faith communities,
when appropriate—these can provide emotional or instrumental support and help to reinforce
engagement with and adherence to treatment
Reviewing comorbidities and drugs—some chronic conditions might be made worse by starting
a particular analgesic agent and some drugs may constitute a contraindication to initiating
a specific analgesic trial
Standardized tools for pain assessment
Measure (No of items)
Brief pain inventory-short form (n=9)w1
Sensory (intensity, location); pain related interference or disability; treatments,
degree of relief provided by treatments; affect
Geriatric pain measure (n=24)w2
Sensory (intensity, temporal pattern); pain related interference or disability; affect
Pain disability index (n=7)w3
Pain related interference or disability
Short-form McGill pain questionnaire (n=15)w4
Sensory; exacerbating or ameliorating factors; affect
PROMIS* pain interference, behavior, intensity itemsw5
Pain related interference or disability; pain behaviors; pain intensity
Sensory (intensity); pain related interference or disability; joint stiffness
Roland Morris disability questionnaire† (n=24)w7
Pain related interference or disability; affect
Numeric rating scale (n=1)w8
Verbal rating scale (n=1)w9
Visual analog scale (n=1)w9
Faces pain scale (n=1)w10
LANSS pain scale (n=7)w11
Sensory (assessment of possible neuropathic pain)
Sensory (assessment of possible neuropathic pain)
WOMAC=Western Ontario and McMaster Universities osteoarthritis index; LANSS=Leeds
assessment of neuropathic symptoms and signs; DN4=Douleur Neuropathique 4 questions.
*Available in long and short form versions: long version for pain interference has
40 items; there are five short form versions for pain interference where the number
of questions varies from 4 to 8; long form version for pain behavior has 39 items,
short form version has 7. PROMIS pain intensity measure has three items.
†Originally developed as tool to measure perceived disability in patients with back
pain. Increasingly used to measure perceived disability due to pain from any cause.
Box 3 lists these and other core elements of the assessment along with sample questions
that can be employed during the interview. Additional guidance about assessment approaches
can be found in UK and US guidelines17
18 and in an international consensus report on this topic.19
Box 3 Elements of a comprehensive geriatric pain assessment
Please tell me all of the places you experience pain or discomfort. What does it feel
like? What words come to mind?
Is your pain or discomfort with you all of the time or does it come and go? How long
has it been present? What makes it better, what makes it worse?
Has pain affected your mood, sense of wellbeing, energy level?
Are you worried about your pain or what may be causing it?
Has pain affected your ability to do every day activities? To do things you enjoy?
How about relating with others? If so, how?
Has pain affected your sleep?
Do you have trouble falling asleep or need to take drugs to help you sleep on account
of your pain?
Attitudes and beliefs
Do you have any thoughts or opinions about experiencing pain at this point in your
life that you believe would be important for me to know?
Do you have any thoughts or opinions about specific pain treatments that you believe
would be important for me to know?
What things do you do to help you cope with your pain? This could be listening to
your favorite music, praying, sitting still, or isolating yourself from others
Treatment expectations and goals
What do you think is likely to happen with the treatment I have recommended?
What are the most important things you hope will happen as a result of the treatment?
Is there anyone at home or in the community that you can turn to for help and support
when your pain is really bad?
A physical examination should be conducted, focusing on the musculoskeletal (is there
evidence of inflammation?) and neurologic (is there evidence of weakness or neuropathy?)
systems. Because many older adults with chronic pain report the presence of weakness,
it is important to distinguish pain induced weakness from true motor weakness. This
can be done by documenting abnormal results from nerve conduction studies or by treating
pain successfully and seeing if the muscle weakness improves. Tackling physical functioning
and risk of falls is critically important, given that pain is associated with these
outcomes. This part of the assessment should include self report and performance based
measures such as gait speed, timed up and go test, balance. The results provide a
baseline against which the functional impact of treatment can be evaluated.
Diagnostic imaging is often overused and does not indicate better care.20 In one study
of Portuguese adults (n=5094) more than half of all respondents with chronic pain
reported undergoing a diagnostic imaging procedure in the previous six months.21 Such
imaging often uncovers incidental findings, leading to more testing, costs, and worry
for patients. An additional concern is the low correlation between pathologic findings
identified by imaging and the extent to which patients report experiencing pain.22
Many patients with major disease identified by imaging report no pain, whereas others
without major disease often report severe pain.22 Diagnostic imaging is appropriate
when the history or physical examination identifies abnormalities that suggest a specific
diagnosis for the pain. Imaging procedures should also be strongly considered in the
presence of “red flags,” to include worsening pain in patients with a history of cancer,
risk factors for infection (injecting drug use, immunosuppressive therapy), and worrisome
constitutional signs or symptoms such as unexplained weight loss, fever, or loss of
Assessing pain in older patients with major cognitive impairment
Patients with limited verbal or cognitive abilities require modified approaches to
assessment. A hierarchy of techniques is recommended, the first including an attempt
to obtain self report data followed by a search for potential causes of the pain,
observing patient behavior (for example, facial expressions, vocalizations, guarding),
obtaining proxy data from family members or caregivers who know the patient well and
can report on whether changes in behavior or activity are very different from baseline,
and conducting an analgesic trial to see whether the behavior resolves with treatment.23
Several tools for behavioral pain assessment have been developed to assess for pain
in non-verbal patients and are reviewed elsewhere.19
What is the approach to management?
Management of pain in later life can be complex; problems with both nociceptive and
neuropathic pain are common and often coexist. Nociceptive pain arises from actual
or threatened damage to non-neural tissue through activation of nociceptors, whereas
neuropathic pain occurs as a consequence of abnormalities in the central or peripheral
somatosensory nervous system.4 Management is further complicated by age related physiologic
changes, which lead to altered drug absorption and decreased renal excretion, sensory
and cognitive impairments, polypharmacy, and multimorbidity, particularly chronic
conditions such as disorders of gait and balance, and kidney, lung, and cardiovascular
disease.16 Other barriers to management include a limited evidence base to guide decisions,
physician concerns about the potential for treatment related harm, as well as older
adults’ beliefs about pain and treatments for the pain. However, it is important to
note that these barriers are not universally present in older adults; an important
tenet of geriatric medicine is that chronologic age does not equal biologic age.
Chronic pain in older patients most often occurs in the setting of multiple comorbidities,
limiting treatment options. A comprehensive management approach should deal with common
sequelae such as depression, isolation, and physical disability, and include both
drug and non-drug treatments. UK and US guidelines on the management of pain in later
life strongly endorse this approach.2
3 Recent data provide support for multimodal treatment approaches. In one randomized
clinical trial (n=454) of overweight or obese older adults with osteoarthritis of
the knee, intensive weight reduction combined with exercise training produced significant
improvements in pain, functional status, and physical performance over an 18 month
period when compared with exercise only (and diet only) control groups.24
In terms of care delivery, collaborative approaches have proved efficacy in the primary
27 One recent randomized clinical trial involving older primary care patients (n=250)
with chronic musculoskeletal pain found that a telephone based collaborative care
management intervention delivered by a nurse care manager, physician pain specialist,
and the patient’s primary care provider led to improved patient outcomes at 12 months,
largely through optimizing non-opioid analgesics by using a stepped care approach.25
Given the complexities of managing most older patients with chronic pain, a multidisciplinary
approach that includes physician, nursing, and social work perspectives is strongly
Social aspects of management
Clinicians are advised to take family responses and dynamics into account when formulating
treatment plans. Older patients’ chronic pain often affects their close relatives
Spouses typically play an important role in caring for older patients, often times
delivering emotional and instrumental support. However, when an older spouse experiences
chronic pain, problems of communication and commitment to the marriage can occur.
Therapeutic interventions directed at patients with chronic pain increasingly involve
the family, most often by including relatives in cognitive behavior therapy (CBT)
or self management training. Although evidence is mixed, several well conducted, randomized
trials suggest that spousal participation in the treatment process can yield measurable
benefits for patients, including enhanced emotional wellbeing and reduced pain levels.28
We are not aware of any literature that has examined the value of home visits for
older adults with chronic pain. Despite a lack of evidence supporting the use of home
visits, clinicians should consider them on a case by case basis because of several
potential benefits, which include clarifying reasons for non-adherence to drug and
behavioral interventions, gathering proxy data that may not be available during an
office visit, and preventing the use of old prescription drugs often stored by patients.
Perhaps the most important benefit is a strengthening of the doctor-patient relationship.
From the physician’s perspective, observing the patient’s environment often offers
intangible but valuable insights into the patient’s condition. From the patient’s
perspective, most feel enormously supported by a physician who cares enough to make
a home visit.
What drug interventions are available?
Table 2 summarizes current UK and US guideline recommendations,2
3 highlights key safety concerns about analgesics, and provides guidance on specific
drug treatments for both nociceptive and neuropathic pain disorders. The use of drug
combinations often results in enhanced analgesic effectiveness, with lower toxicity
than is seen with the use of a single agent at higher doses, and is encouraged.30
Guideline recommendations for drug management of chronic pain
Quality of evidence†
Use for mild to moderate pain
Liver toxicity a concern at higher doses, particularly from unintentional overdose
Use for shortest time possible; may be appropriate when other treatments have failed
Selective and non-selective NSAIDs associated with adverse gastrointestinal, renal,
and cardiovascular side effects
Use as alternative to oral NSAIDs, particularly when pain is localized
Safety of topical NSAIDs in patients receiving anticoagulation or with renal impairment
Consider for use in patients who do not respond to paracetamol/NSAIDs
Increased risk of seizures or serotonin syndrome when used with antidepressants; side
effect profile similar to that of opioids
Use for moderate to severe pain or with substantial impairments in functioning or
quality of life and when other treatments have been unsuccessful
Side effects limit use (constipation, sedation, nausea)
Avoid tertiary tricyclics (for example, amitriptyline) because of concerns over adverse
side effects; consider trial of secondary amine (nortriptyline) for neuropathic pain
Side effects limit use, electrocardiographic monitoring required owing to risk of
QTc prolongation; serum level monitoring also recommended
Anticonvulsants (for example, pregabalin, gabapentin)
Use for neuropathic pain
Side effects limit use (for example, sedation, peripheral edema); dose adjustment
necessary in those with renal impairment
NSAIDs=non-steroidal anti-inflammatory drugs.
*Recommendations present in both UK and US guidelines.2 3
†Quality of evidence ratings are from the 2009 American Geriatrics Society guideline.
Because of its favourable safety profile, paracetamol (acetaminophen) is the preferred
treatment for older patients with mild or moderate pain. In one meta-analysis of seven
randomized controlled trials comparing paracetamol with placebo, paracetamol (up to
4 g daily) was found to be modestly effective in reducing pain, which decreased on
average by 4 points on a scale of 0-100. The number needed to treat ranged from 4
to 16. Paracetamol did not improve physical function or stiffness when compared with
placebo..31 While it is not associated with significant cardiovascular, renal, or
gastrointestinal effects,3 unintentional overdose of paracetamol is an important cause
of hepatotoxicity. Patients should be counseled to not exceed the maximum recommended
Non-steroidal anti-inflammatory drugs
Oral non-steroidal anti-inflammatory drugs (NSAIDs) have established gastrointestinal,
cardiovascular, and renal risks, which increase with age. Oral NSAIDs can be effective
in some patients but are safest when used for pain flares (transient increases in
pain that typically persist for hours to days). The current evidence base provides
little guidance about the NSAID for safest use in this patient population. A network
meta-analysis examined the cardiovascular safety of various NSAIDs and found that
naproxen was the least harmful compared with other non-selective (for example, ibuprofen)
and selective (for example, celecoxib) NSAIDs.32 These data indicate that naproxen
is most appropriate (compared with other NSAIDs) for patients with cardiovascular
risk factors. Risk of renal and gastrointestinal injury must also be weighed, however,
before initiating any trial involving NSAIDs. If a trial of an NSAID is undertaken,
have the patient return to the office within two weeks to ask about treatment benefit
and gastrointestintal side effects, check blood pressure, and carry out renal function
Topical NSAIDs represent an alternative to oral NSAIDs, are generally well tolerated,
and should be considered, especially for patients with localized pain.
Opioids may be considered when an older patient’s pain has not responded to other
treatments or when major functional impairment persists despite treatment. The short
term efficacy of opioid use (≤12 weeks) among older adults has been established.33
In a retrospective cohort study of (n=133) older patients (mean age 82) newly started
on an opioid because of pain due to chronic musculoskeletal conditions, reductions
in pain were recorded in 66% of participants.34 However, opioids were discontinued
in 48% of the participants, mostly as a result of poorly tolerated side effects, including
constipation, changes to mental status, and nausea. Given the established risks associated
with opioid use,35 the potential negative effects must be weighed against the consequences
of untreated or partially treated pain. A recent systematic review found limited evidence
in support of long term opioid treatment, and the risk for serious harm increased
in line with opioid dose.35 If an opioid trial is undertaken, it is important to closely
monitor (that is, biweekly during the initiation and dose titration phase of treatment)
whether treatment goals are being met. If not, the drug should be tapered and discontinued.
There is no evidence to support the use of one weak opioid (for example, hydrocodone,
codeine) over another when the response to paracetamol or a NSAID is lacking. Selection
of a specific opioid depends on the clinician’s clinical experience and knowledge,
the patient’s previous experiences, and availability of the drug in local pharmacies.
Strong opioids (for example, morphine, hydrocodone) should not be given to patients
who have never used opioids. Efforts to reduce opioid related risks are particularly
appropriate given dramatic increases in and complications associated with opioid use.
These include the use of screening tools (for example, the screener and opioid assessment
for people with pain, opioid risk tool) that can be used to assess risk for the likelihood
of opioid misuse, as well as guide decisions about the extent of monitoring needed
if an opioid trial is undertaken. Such monitoring might extend to the use of urine
toxicology screens on a periodic basis. Before older patients are prescribed opioid
analgesics, physicians should be satisfied with arrangements for safe storage of the
drug, given the risk for drug diversion (that is, use of the drug for a purpose other
than pain reduction). In terms of initiating a given opioid trial, no special dosing
guidelines exist for older patients. Beginning at the lowest possible dose and titrating
upwards based on tolerability and efficacy is recommended, given that age is associated
with a greater incidence of treatment related adverse effects. This risk is increased
by the presence of multiple comorbidities, polypharmacy, and physiologic vulnerability.
Careful surveillance is necessary after beginning an analgesic trial. Frequent telephone
or email contact is recommended to assess for and deal with any adverse effects.
What psychological interventions are available?
There is optimism about the role of psychological interventions as treatment for older
patients with chronic pain.36
Cognitive behavioral therapy
The use of CBT is promising.37 CBT is used to enhance patients’ control over pain,
based on the premise that an individual’s beliefs, attitudes, and behaviors play a
central role in the experience of pain. Standard CBT protocols instruct patients in
the use of specific cognitive and behavioral techniques, teach them how certain thoughts,
beliefs, attitudes, and emotions influence pain, and highlight the patient’s own role
in controlling and adapting to chronic pain. CBT techniques are underutilized, particularly
among older adults with chronic pain. Few providers have been trained to deliver the
protocols for pain, particularly in less developed countries.38 Early innovation in
remote therapy that makes use of communication technology may help to overcome this
barrier. Although the quality of the early trials in this area is poor, the use of
ehealth and mhealth technologies can improve access to treatments and could improve
the treatments.39 Particularly promising are efforts to train non-psychologists in
CBT delivery and related therapies, which could increase the reach of these treatments.40
In addition, two recent high quality trials broaden the scope of treatment to include
sustainable self management practices in primary care.41
42 In one trial, investigators evaluated a CBT based self management program for use
by older patients with chronic pain in primary care.41 Significant improvements in
distress from the pain, disability, and self efficacy were found in patients who received
CBT training compared with an exercise only and wait list control group. Communicating
with older patients—particularly those who are reluctant to try behavioral treatments—that
using non-drug as well as drug treatments is the standard of care can be helpful.
Routinely inquiring about and dealing with patient barriers to engagement with treatment
(for example, belief that non-drug treatments are ineffective) is also recommended.
Self management programs
Self management programs merge physical, psychological, and social dimensions and
adopt a largely educational approach, teaching patients specific strategies to reduce
pain by changing their behavioral, cognitive, and emotional responses to pain and
building self efficacy for managing pain and its sequelae. These programs combine
education about pain and its consequences and training in relaxation and communication
skills. Among the best known of these programs is the Arthritis Foundation self help
program (http://patienteducation.stanford.edu/programs/asmp.html). Evidence about
the value of self management programs for pain is mixed. Several reviews have reported
positive treatment outcomes,43
44 whereas others have not.45
46 Despite the conflicting data, we believe it is reasonable to encourage patient
participation in self management, and a clearer matching of tailored treatment content
to specific outcomes.47
What rehabilitative and exercise approaches are available?
Exercise interventions for older adults with chronic pain are evidenced based, underutilized,
and should be a core component of any long term treatment plan. Primary components
include training in balance, flexibility, endurance, and strengthening, the mix of
which should be tailored to best meet the needs of each patient. Clinicians can refer
patients to physiotherapists to develop an exercise program. Physiotherapists can
also reinforce related concepts to include coaching on risk of falls, balance training,
body mechanics, and pacing. Simple physician advice to remain physically active despite
pain, in the absence of a specific exercise routine, is ineffective.
Community based programs include the evidence based Arthritis Foundation exercise
program (www.cdc.gov/arthritis/interventions/physical_activity.htm), which is delivered
in a group format. Classes are held 1-3 times a week for eight weeks. Health or fitness
trainers (such as exercise therapists) lead the groups, which focus on specific exercises
appropriate for patients with arthritis or arthritis related diseases. In a recent
uncontrolled study (n=110) of a group based exercise training program for older adults
with arthritis, participation led to significant improvements in physical functioning.48
Tai Chi and yoga programs should also be considered, with the caveat that the instructor
should be properly qualified.18 Exercise based programs are low cost and accessible
in many communities.49 Healthcare providers should familiarize themselves with these
Practitioners should consider the preferences of individual patients when prescribing
exercise, including the preferred location (for example, gym, home) as well as type
of exercise. Older patients with chronic pain may not have access to facilities for
exercise or may lack the motivation to engage. It is important to address these barriers
or adherence will be low. In support of this approach is a randomized controlled trial
of community dwelling older adults (n=56) with chronic pain.50 In this study, participants
randomized to an eight week group based exercise program that included motivational
interviewing techniques delivered by a physiotherapist showed significant improvements
in pain intensity, self efficacy, anxiety level, and mobility compared with a group
based activity control group.50
When should patients be referred to a pain specialist?
Practitioners should refer patients when pain is unresponsive (or poorly responsive)
to standard treatments, a psychiatric condition (for example, active substance use
disorder, excluding nicotine) or medical condition (for example, hepatic or renal
dysfunction) would complicate management, there are concerns about misuse of opioids,
and procedures (for example, nerve block) may help to clarify a diagnosis or are indicated
for the treatment of a given pain disorder.
What is the role of mobile health technology?
Recent advances in mobile health technologies suggest these devices may play a role
in the near future by facilitating the collection and transmission of information
for the assessment of pain.51
52 These devices could potentially improve patient care through more effective monitoring
of treatment outcomes, enhanced patient-provider communication, and by providing new
ways to deliver treatment.51 For example, a recent SMS text message based social support
intervention delivered by mobile phone was found to reduce pain and pain interference
levels among patients with chronic pain.52
What limitations exist in the evidence base about treatment?
Although the number of well designed studies evaluating drug or non-drug treatments
for older adults with chronic pain is growing, there are important limitations in
the existing evidence base. Factors limiting the generalizability of findings include
the use of various outcome measures, which make it difficult to compare across studies,
short duration of most trials (≤12 weeks), lack of diversity in study populations
(inclusion of mostly white, non-Hispanic patients), and greater enrolment of young-old
participants (with few participants aged ≥80) without major comorbidity. Questions
about treatment adherence, as well as the long term safety and efficacy of these modalities
in older populations remain inadequately defined. In terms of behavioral treatments,
patient factors that positively (or negatively) impact treatment outcomes remain inadequately
defined. Identifying optimal strategies for the delivery of behavioral treatment (for
example, individual versus group based and online versus mobile health approaches)
warrant further attention.36
Despite these knowledge gaps, we recommend that healthcare providers educate older
patients about diverse treatment approaches and encourage their use, to include both
drug and non-drug modalities, as a way of broadening their “pain management portfolio.”
Lack of evidence does not mean evidence of no effect; clinicians must make treatment
decisions based on the interaction of individual needs and existing evidence. Given
low rates of use of many non-drug management approaches in older patients, encouraging
engagement in and adoption of these modalities, to include cognitive behavioral therapy
and exercise is particularly recommended.
Questions for future research
What are the implications of ethnic and cultural diversity on the experience of pain
among older people, and the effectiveness of interventions?
What are the best ways to measure outcomes in geriatric pain research, including both
observable and subjective dimensions?
Can access to psychological therapies be improved by training non-psychologists in
delivering them and by using mhealth and ehealth solutions?
What effect does pain have on cognitive ability and motivation in older people, and
how can this be best managed with cognitive behavioral therapy?
How can the evidence base in trials of pharmacologic, physical, and psychological
treatments be improved for older people?
Should the inclusion of older people in the design of novel interventions be mandatory?
What evidence based approaches work best to maximize treatment adherence?
Tips for non-specialists
Pain is more than just a sensory event; assessing for the presence and severity of
pain captures only a small part of the pain experience
Diagnostic imaging is often overused and does not equal better care
Consider specialist referral for older patients who have complicated psychiatric histories,
debilitating pain, or pain that does not respond to customary treatments
Use combinations of analgesic drugs to enhance analgesic effectiveness
Non-drug approaches to include exercise and cognitive behavioral approaches are underutilized.
Educate older patients about these approaches and identify local practitioners or
agencies that provide them
Implement surveillance plan to assess treatment efficacy, tolerability, and adherence
with each new treatment
Additional educational resources
Resources for healthcare professionals
International Association for the Study of Pain (www.iasp-pain.org/)—Offers extensive
resources for healthcare professionals, including listings of educational opportunities,
resources on management and treatment, and clinical updates (many countries have affiliates
American Geriatrics Society (www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2009/)—Provides
resources and guidelines for clinicians in providing care to older adults with pain
European Pain Federation (www.efic.org/)—Promotes research, education, clinical management,
and professional practice on pain, with training and educational opportunities
Resources for patients
British Pain Society (www.britishpainsociety.org/)—Provides extensive information
for people with pain, including suggested readings, frequently asked questions, and
free downloadable publications on various aspects of pain management
American Chronic Pain Association (www.theacpa.org/)—Offers education and support
for people in pain, including educational online resources and a network of support
groups in the United States, United Kingdom, and other countries
Arthritis Foundation (www.arthritis.org/)—Offers programs, practical tips, and education
to help people to better manage arthritis related pain
A patient’s perspective
I have lived with chronic back pain for over 30 years. Early on I had surgery on my
back that helped for maybe six months, but then the pain returned and has been with
me ever since. It has affected my life in many ways: I don’t have as much energy as
I would like, I can only do housework for short periods before my back starts to hurt,
and my kids only know me as a person with chronic back pain. I use different techniques
to help me manage it. First off, having a supportive spouse and family is very important.
I also find massage, which I get several times a week, to be incredibly helpful. I
also go to the gym where I do stretches, walk on the treadmill, and do the exercise
bike and elliptical for short periods (five minutes each) before my back starts to
bother me. I do take pain medications; I will take ibuprofen for short periods. I
also take hydrocodone when the pain is really bad but don’t like taking it regularly
because my mother had an addiction problem, which is a concern. I would say I have
learned to live with the pain and won’t let it defeat me.
Sally Smith, New York City