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The Management of Persistent Pain in Older Persons
AGS Panel on Persistent Pain in Older Persons
scribed are those who are most frail, with health and dis- Background and Significance
ability problems typically encountered in the older popula-tion. By age 75 many persons exhibit some frailty and Pain is an unpleasant sensory and emotional experi- chronic illness. In the population above age 75, morbidity, ence.1 Pain is a complex phenomenon derived from sen- mortality, and social problems rise rapidly, resulting in sory stimuli or neurologic injury and modified by individ- substantial strains on the healthcare system and societal ual memory, expectations, and emotions.2 Pain is usually safety nets. This group represents the fastest growing seg- associated with injury or a pathophysiologic process that ment of the total population.5 The greatest challenges in causes an uncomfortable experience and is usually de- geriatric medicine are represented by the oldest, sickest, scribed in such terms. Although there are no objective bio- and most frail patients with multiple medical problems logic markers of pain, an individual's description and self- and few social supports. The guideline panel focused its report usually provides accurate, reliable, and sufficient attention on this group as it prepared this update.
evidence for the presence and intensity of pain.3 Persistent pain is common in older people.6 A Louis Persistent pain can be defined as a painful experience Harris telephone survey found that one in five older Amer- that continues for a prolonged period of time that may or icans (18%) are taking analgesic medications regularly may not be associated with a recognizable disease process.
(several times a week or more), and 63% of those had The terms persistent and chronic are often used inter- taken prescription pain medications for more than 6 changeably in the medical literature. Unfortunately for months.7 Older people are more likely to suffer from ar- many elderly persons, chronic pain has become a label as- thritis, bone and joint disorders, back problems, and other sociated with negative images and stereotypes often associ- chronic conditions. This survey also found that 45% of ated with longstanding psychiatric problems, futility in patients who take pain medications regularly had seen treatment, malingering, or drug-seeking behavior. The three or more doctors for pain in the past 5 years, 79% of term persistent pain may foster a more positive attitude by whom were primary care physicians. Previous studies have patients and professionals for the many effective treat- suggested that 25% to 50% of community-dwelling older ments that are available to help alleviate suffering.4 people suffer important pain problems.6,8,9 Pain is also The clinical manifestations of persistent pain are com- common among nursing home residents.10,11 It has been es- monly multifactorial. Because of the complex interplay timated that 45% to 80% of them have substantial pain among these factors across several domains (physiologic, that is undertreated. Studies of both the community-dwell- psychologic, and social), discriminating which factors are ing and nursing home populations have found that older most important for the purpose of treatment can be very people commonly have several sources of pain, which is challenging. Further complicating this task is the fact that not surprising, as older patients commonly have multiple pain expression and hence the importance of specific fac- medical problems. A high prevalence of dementia, sensory tors commonly vary, not only across individuals but also impairments, and disability in this population make as- over time in one individual.
sessment and management more difficult.
Elderly persons have been defined by demographers, The consequences of persistent pain among older peo- insurers, and employers as those aged 65 years and over.
ple are numerous. Depression, anxiety, decreased social- In healthcare discussions, the elderly persons often de- ization, sleep disturbance, impaired ambulation, and in-creased healthcare utilization and costs have all beenfound to be associated with the presence of pain in olderpeople. Although less thoroughly described, many otherconditions are known to be worsened potentially by the This guideline was developed and written under the auspices of the Ameri- presence of pain, including gait disturbances, slow rehabil- can Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons and itation, and adverse effects from multiple drug prescrip- approved by the AGS Board of Directors on April 8, 2002.
Address correspondence to Elvy Ickowicz, MPH, Manager, Professional Psychosocial factors affect and are affected by pain in Education and Special Projects, American Geriatrics Society, 350 Fifth Avenue, Suite 801, New York, NY, 10118. email: eickowicz@ older patients. It has been shown that older adults with good coping strategies have significantly lower pain and 50:S205–S224, 2002 2002 by the American Geriatrics Society CLINICAL PRACTICE GUIDELINE
JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT psychologic disability.13 Depression is commonly associ- it is not clear how this might affect an individual's experi- ated with pain in the older patient; researchers have found ence of pain. Experimental studies of pain sensitivity and a significant correlation between pain and depression pain tolerance across all ages (young and old persons) among nursing home residents, even after controlling for have had mixed results.16 In the final analysis, age-related self-reported functional status and physical health.14 Older changes in pain perception are probably not clinically sig- patients with cancer pain rely heavily on family and infor- mal caregivers; for these patients and caregivers, pain can The most common strategy to manage pain is to use be a metaphor for death, resulting in increased suffering.15 analgesic drugs. Unfortunately, older patients have been Classifying persistent pain in pathophysiologic terms systematically excluded from clinical trials of such drugs.
may help the clinician select therapy and determine prog- In one report of 83 randomized trials of nonsteroidal anti- nosis.12 Treatment strategies targeted specifically to under- inflammatory drugs (NSAIDs) including nearly 10,000 lying pain mechanisms are more likely to be effective. It is subjects, only 2.3% were aged 65 or over and none were beyond the scope of this guideline to describe the patho- aged 85 or over.18 Despite the fact that older people are physiology of individual pain syndromes in detail, but four more likely to experience the side effects of analgesic med- basic categories that encompass most syndromes can be ications, they appear to be more sensitive to analgesic properties, especially those of opioid analgesics.19 For ex-ample, single-dose studies comparing younger and older • Nociceptive pain may be visceral or somatic and is patients with postoperative and cancer pain have observed most often derived from the stimulation of pain re- higher pain relief and longer duration of action among ceptors. Nociceptive pain may arise from tissue in- older patients for morphine20 and other opioid drugs.21 flammation, mechanical deformation, ongoing in- The use of opioid analgesic drugs for persistent non– jury, or destruction. Examples include inflammatory cancer-related pain remains controversial, although con- or traumatic arthritis, myofascial pain syndromes, sensus statements from major professional pain organiza- and ischemic disorders. Nociceptive mechanisms tions endorse their use in appropriate situations (e.g., usually respond well to traditional approaches to American Academy of Pain Management and American pain management, including common analgesic Pain Society). Reluctance to prescribe these drugs has medications and nonpharmacologic strategies.
probably been over-influenced by political and social pres- • Neuropathic pain results from a pathophysiologic sures to control illicit drug use.22, 23 In fact, the incidence of process that involves the peripheral or central ner- addictive behavior among patients taking opioid drugs for vous system. Examples include diabetic neuropathy, medical indications appears to be very low.24,25 Moreover, trigeminal neuralgia, post-herpetic neuralgia, post- the exercise of careful professional responsibility reduces stroke central or thalamic pain, and postamputation the risk of abuse. This does not imply that opioid drugs phantom limb pain. These pain syndromes do not should be used indiscriminately, but only that fear of ad- respond as predictably as do nociceptic pain prob- diction and other side effects does not justify failure to lems to conventional analgesic therapy. However, treat severe pain.
they have been noted to respond to unconventionalanalgesic drugs, such as tricyclic antidepressants, Guideline Development Process and Methods
anticonvulsants, or antiarrhythmic drugs.
The American Geriatrics Society published the prede- • Mixed or unspecified pain is usually regarded as cessor of this clinical practice guideline, entitled The Man- having mixed or unknown mechanisms. Examples agement of Chronic Pain in Older Persons, in 1998.12 include recurrent headaches and some vasculitic Since then, advances in pharmacology and the availability pain syndromes. Treatment of these syndromes is of new drugs and strategies for the management of pain in more unpredictable and may require trials of differ- older persons have been made. This panel has focused on ent or combined approaches.
updating and revising the earlier recommendations, using • There may be rare conditions (e.g., conversion reac- the latest information about pain management in elderly tion) where psychologic disorders are responsible persons. The goal is to provide the reader with (1) an over- for the onset, severity, exacerbation, or persistence view of the principles of pain management as they apply of pain. Patients with these disorders may benefit specifically to older people and (2) specific recommenda- from specific psychiatric treatments, but traditional tions to aid in decision making about pain management medical interventions for analgesia are not indi- for this population. This is not meant to be an exhaustive treatise on the subject, but, rather, a practical guide for cli- Age-associated changes in pain perception have been a nicians. It also provides a synthesis of existing literature topic of interest for many years, ever since older adults and the consensus among experts familiar with clinical have been observed to present with unusual manifesta- pain management and research in older persons. In focus- tions of common illness. Neuroanatomic and neurochemi- ing on issues unique to the geriatric population and areas cal findings have shown that the perception of pain and its that have been omitted or less well developed in previous modulation in the central nervous system are very elabo- publications, we hope to be helpful to clinicians as well as rate and complex.16 Unfortunately, little is known about to researchers and policy makers. Ultimately, we hope the the effect of age alone on most of these complex neural beneficiaries of this work will be those patients who re- pain functions. Although alterations of transmission along quire effective pain management to maintain their dignity, A-delta and C nerve fibers may be associated with aging,17 functional capacity, and overall quality of life.
JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT CLINICAL PRACTICE GUIDELINE
The recommendations that follow began with the ear- lier work of the Panel on Chronic Pain in Elderly Persons.
Table 1. Key to Designations of Quality and Strength of
Evidence
The panel, convened in 2001, included experts in ethics,family medicine, geriatrics, nursing, pain management, Quality of Evidence
pharmacy, psychiatry, psychology, rehabilitation medi-cine, rheumatology, and social work. The panel drafted Evidence from at least one properly the revised recommendations and then conducted a review randomized, controlled trial of existing literature to evaluate the evidence available re- Evidence from at least one well-designed lated to each recommendation. More than 4,122 citations clinical trial without randomization, from were identified from sources, including computerized key cohort or case-controlled analytic studies, word searches for each recommendation (PubMed), per- from multiple time-series studies, or from sonal citation libraries of the panel members, and refer- dramatic results in uncontrolled experiments ences from the texts of some individual articles. These cita- Evidence from respected authorities, based tions were screened for evidence-based content related to on clinical experience, descriptive studies, the recommendations, and more than 2,089 abstracts were or reports of expert committees.
obtained for further analysis by a panel member. Finally,more than 520 full-text English-language data-based arti- Strength of Evidence
cles were obtained and summarized for detailed analysisby panel members. The data from these articles reporting Good evidence to support the use of a formal meta-analyses, randomized controlled trials, other recommendation; clinicians "should do clinical trials, and descriptive or correlational studies were this all the time" then reviewed to determine the strength of evidence and Moderate evidence to support the use of a quality of evidence criteria for the recommendations.
recommendation; clinicians "should do Groups of the panel members then assigned a designation this most of the time" of the strength and the quality of evidence to each recom- Poor evidence either to support or to reject mendation. (See Table 1 for a key to the designations the use of a recommendation; clinicians "may or may not follow the It is important to note that some of the recommenda- tions are based on clinical experience and consensus ofpanel members without scientific evidence. Existing evi- Moderate evidence against the use of a dence-based literature on the assessment and management recommendation; clinicians "should of persistent pain specifically in older people was found to be very limited in sample and design. Much of the litera- Good evidence against the use of a ture presents persistent pain in a disease-specific approach, recommendation, which is therefore and the number of pain-producing diseases reported is very large. Few randomized clinical trials consisting en-tirely of subjects aged 75 years and over were identified,and no formal meta-analyses of multiple studies of older The recommendations that follow have been divided subjects could be found. The majority of controlled trials into four sections: Assessment of Persistent Pain, Pharma- and meta-analyses were derived from samples consisting cologic Treatment, Nonpharmacologic Strategies, and Rec- of younger patients. The panel occasionally drew on data ommendations for Health Systems That Care for Older derived from studies of younger patients that could be rea- Persons. For each section, general principles are followed sonably extrapolated to older persons. However, data de- by the panel's specific recommendations for improving the scribing persistent pain in younger populations could not clinical assessment and management of persistent pain in always be easily extrapolated to the oldest old or to care older persons. Readers should recognize that medical sci- settings where older patients are often encountered. Once ence is a constantly changing field. As new data are accu- the literature review was completed, evidence was rated, mulated and re-analyzed, clinicians must keep abreast of and results were disseminated for external review by ex- new developments as evidence emerges that may have im- perts from a variety of other organizations with interest in portant implications for implementation of specific recom- this subject.
mendations contained in this guideline. These recommen- Some issues in persistent pain management are be- dations are meant to serve as a guide and should not be yond the scope of this project and so are not addressed by used in lieu of critical thinking, sound judgment, and clini- guideline recommendations. For example indicators and cal experience.
outcomes of many surgical procedures were not reviewed.
Clearly, a number of barriers still prevent the improve-ment of pain management in clinical practice; these barri- ASSESSMENT OF PERSISTENT PAIN
ers often involve larger issues of professional education, public and professional attitudes, economics, law, andhealth system issues. We hope that this work will stimulate Pain management is most successful when the under- others to collaborate and develop new solutions for the lying cause of pain is identified and treated definitively. A significant issues not addressed by this panel.
thorough initial assessment and an appropriate work-up CLINICAL PRACTICE GUIDELINE
JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT are necessary to determine whether disease-modifying in- terventions could address the cause of a patient's persis- (quality and strength of evidence ratings follow each tent pain.26 Assessment should include evaluation of acute recommendation: see Table 1) pain that might indicate new concurrent illness rather thanexacerbation of persistent pain.
I. On initial presentation or admission of any older In the evaluation process, interdisciplinary assessment person to any healthcare service, a healthcare profes- may help identify all the potentially treatable contributors sional should assess the patient for evidence of per- to the pain. For those in whom the underlying cause is not sistent pain. (IIB) remediable or is only partially treatable, an interdiscipli- II. Any persistent pain that has an impact on physical nary assessment and treatment strategy is often indi- function, psychosocial function, or other aspects of cated.27 Patients who need specialized services or skilled quality of life should be recognized as a significant procedures should be referred to a specialist with appro- priate expertise. Such patients include those with debilitat- III. All patients with persistent pain that may affect ing psychiatric complications, substance abusers, and physical function, psychosocial function, or other as- those with life-altering intractable pain.
pects of quality of life should undergo a comprehen- The most accurate and reliable evidence of the exist- sive pain assessment, with the goal of identifying all ence of pain and its intensity is the patient's report.28 Clini- potentially remediable factors. (See Table 2 for sam- cians as well as family and caregivers must believe patients ple pain interview questions.) Assessment should fo- and take their reports of pain seriously. Even patients with cus on recording a sequence of events that led to the mild to moderate cognitive impairment can be assessed present pain complaint, and on establishing a diag- with simple questions and screening tools.29-36 nosis, a plan of care, and likely prognosis: (IIIB) A variety of pain scales have been accepted for use among older adults, even among those with mild to mod- 1. Initial evaluation of present pain complaint erate cognitive impairment. A verbally administered 0–10 should include pain characteristics, such as scale is a good first choice for measuring pain intensity in intensity, character, frequency (or pattern, or most older persons. The Joint Commission on Accredita- both), location, duration, and precipitating tion of Healthcare Organizations has often accepted and and relieving factors. (IIIA) many institutions have adopted this method for routine as- 2. Initial evaluation should include a description sessment or "Pain — the 5th Vital Sign" monitoring pro- of pain in relation to impairments in physical grams. In this case, the clinician simply asks the patient and social function (e.g., activities of daily liv- "On a scale of zero to ten, with zero meaning no pain and ing [ADLs], instrumental activities of daily ten meaning the worst pain possible, how much pain do living [IADLs], sleep, appetite, energy, exer- you have now?" However, a substantial portion of older cise, mood, cognitive function, interpersonal adults (with and without cognitive impairment) may have and intimacy issues, social and leisure activi- difficulty responding to this scale. Other verbal descriptor ties, and overall quality of life). (IIA) scales, pain thermometers, and faces pain scales also have 3. Initial evaluation should include a thorough accepted validity in this population and may be more reli- analgesic history, including current and previ- able in those who have difficulty with the verbally admin- ously used prescription medications, over-the- istered 0–10 scale. Thus it is important to utilize a scale counter medications, complementary or alter- that is appropriate for the individual and document and native remedies, and alcohol use or abuse.
use the same tool with each assessment.26 Figure 1 illus- The effectiveness and any side effects of cur- trates examples of a pain thermometer and a faces scale rent and previously used medications should that have been studied in older populations.
be recorded. (IIIB) Older patients themselves may make accurate pain as- 4. The patient's attitudes and beliefs regarding sessment difficult.37,38 They may be reluctant to report pain and its management, as well as knowl- pain despite substantial physical or psychologic impair- edge of pain management strategies, should ment. Many older people expect pain with aging and do be assessed. (IIB) not believe that their pain can be alleviated. They may fear 5. Effectiveness of past pain-relieving treatments the need for diagnostic tests or medications that have side (both traditional and complementary or alter- effects, or fear addiction to and dependence on strong an- native) should be evaluated. (IIIB) algesics. Some patients accept pain and suffering as atone- 6. The patient's satisfaction with current pain ment for past actions.10 While denying the presence of treatment or health should be determined and pain, many older adults will acknowledge discomfort, concerns should be identified. (IIIB) hurting, or aching.39-41 Sensory and cognitive impairment, B. Physical examination common among frail older people, make communication 1. Physical examination should include careful more difficult; fortunately, pain can be assessed accurately examination of the site of reported pain, com- in most patients by the use of techniques adapted for the mon sites for pain referral, and common sites individual's handicaps.31,42 Assessment and treatment of pain in older adults. (IIIA) strategies need to be sensitive to culture and ethnicity, as 2. Physical examination should focus on the well as the values and beliefs of individual patients and musculoskeletal system (e.g., myofascial pain, families. Information from family and other caregivers fibromyalgia, inflammation, deformity, posture, should also be included in the assessment.
leg length discrepancy). Practitioners skilled JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT CLINICAL PRACTICE GUIDELINE
Figure 1. Samples of two pain intensity scales that have been studied in older persons. Directions: Patients should view the figure
without numbers. After the patient indicates the best representation of their pain, the appropriate numerical value can be assigned to
facilitate clinical documentation and follow-up. Source: The faces scale is adapted from Pain 1990; 41(2):139-150. With permission
from Elsevier Science—NL, Sara Biergerjartstraat 25. 1055 KV Amsterdam, The Netherlands. The thermometer is adapted with per-
mission from Keela Herr.
in musculoskeletal examination should be con- hyperalgesia, hyperpathia, allodynia, numb- sidered for consultation (e.g., physical ther- ness, paresthesia, other neurologic impair- apy, occupational therapy, physiatry). (IIIA) 3. Physical examination should focus on the 4. Initial assessment should include observation neurologic system (e.g., search for weakness, of physical function (e.g., measures of ADLs, CLINICAL PRACTICE GUIDELINE
JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT burning, discomfort, aching, soreness, heavi- Table 2. Sample Questions in a Pain Interview
ness, tightness). (IIIA) 1. How strong is your pain right now? What was the worst/ 3. A quantitative assessment of pain should be re- average pain over past week? corded by the use of a standard pain scale that 2. How many days over the past week have you been unable is sensitive to cognitive, language, and sensory to do what you would like to do because of your pain? impairments (e.g., scales adapted for visual, 3. Over the past week, how often has pain interfered with your hearing, foreign language, or other handicaps ability to take care of yourself, for example, with bathing, common in elderly persons). A variety of verbal eating, dressing, and going to the toilet? descriptor scales, pain thermometers, numeric 4. Over the past week, how often has pain interfered with your rating scales, and facial pain scales have accept- ability to take care of your home-related chores, such as able validity and are acceptable for many older going grocery shopping, preparing meals, paying bills, and adults. (See Figure 1 for examples of some com- monly used pain-intensity scales.) (IIA) 5. How often do you participate in pleasurable activities such 4. The use of a multidimensional pain instrument as hobbies, socializing with friends, travel? Over the past that evaluates pain in relation to other domains week, how often has pain interfered with these activities? (e.g., the Pain Disability Index43 or the Brief 6. How often do you do some type of exercise? Over the past Pain Inventory44) should be considered. (IIB) week, how often has pain interfered with your ability to 5. Elderly persons with limited attention span or impaired cognition should receive repeated in- 7. How often does pain interfere with your ability to think structions and be given adequate time to re- spond. Assessment may be done in several steps; 8. How often does pain interfere with your appetite? Have you it may require assistance from family or care- givers, and planning in advance of the visit. (IIIB) 9. How often does pain interfere with your sleep? How often 6. Patients should be queried about symptoms over the past week? and signs that may indicate pain, including re- 10. Has pain interfered with your energy, mood, personality, or cent changes in activities and functional sta- relationships with other people? tus; they should also be observed for verbal 11. Over the past week, how often have you taken pain and nonverbal pain-related behaviors and changes in normal functioning. (See Table 3 12. How would you rate your health at the present time? for some common pain indicators.) (IIA) Adapted with permission from Weiner D, Herr K, Rudy T. (eds.). Persistent Pain 7. Patients can also be asked about their worst in Older Adults: An Interdisciplinary Guide for Treatment. New York: Springer pain experience over the past week. (IIB) 8. With mild to moderate cognitive impairment, assessment questions should be framed in thepresent tense because patients are likely to performance measures such as range of mo- have impaired recall. (IIB) tion, get-up-and-go test, or others). (IIA) IV. For the older adult with moderate to severe demen- C. Comprehensive pain assessment should include tia or who is nonverbal, the practitioner should at- results of pertinent laboratory and other diagnos- tempt to assess pain via direct observation or history tic tests. Tests should not be ordered unless their from caregivers. (See Figure 2 for an algorithm for results will affect decisions about treatment. (IIIB) assessing pain in cognitively impaired persons.) D. Initial assessment should include evaluation of A. Patients should be observed for evidence of pain- psychologic function, including mood (e.g., de- related behaviors during movement (e.g., walk- pression, anxiety), self-efficacy, pain coping ing, morning care, transfers). (IIA) skills, helplessness, and pain-related fears. (IIA) B. Unusual behavior in a patient with severe de- E. Initial assessment should include evaluation of mentia should trigger assessment for pain as a social support, caregivers, family relationships, potential cause. (IIA) work history, cultural environment, spirituality, V. The risks and benefits of various assessment and and healthcare accessibility. (IIB) treatment options should be discussed with patients F. Cognitive function should be evaluated for new and family, with consideration for patient and fam- or worsening confusion. (IIA) ily preferences in the design of any assessment or G. For the older adult who is cognitively intact or treatment strategy. (IIIC) who has mild to moderate dementia, the practi- VI. Patients with persistent pain should be reassessed tioner should attempt to assess pain by directly regularly for improvement, deterioration, or compli- querying the patient. (IIA) 1. Quantitative estimates of pain based on clini- A. The use of a pain log or diary with regular en- cal impressions or surrogate reports should tries for pain intensity, medication use, mood, re- not be used as a substitute for self-report un- sponse to treatment, and associated activities less the patient is unable to reliably communi- should be considered. (IIIC) cate his or her pain. (IIA) B. The same quantitative pain assessment scales 2. A variety of terms synonymous with pain should be used for initial and follow-up assess- should be used to screen older patients (e.g., JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT CLINICAL PRACTICE GUIDELINE
It is rare that any two patients respond with exactly Table 3. Common Pain Behaviors in Cognitively Impaired
the same degree of relief or side effects to the same pain-re- lieving drugs. Therefore, individually tailored therapeutic trials are the hallmark of effective pharmacotherapy for Slight frown; sad, frightened face persistent pain. Titrating drugs while monitoring thera- Grimacing, wrinkled forehead, closed or tightened eyes peutic and adverse effects should be done with consider- Any distorted expression ation for specific subjective and objective endpoints. Pa- tients with excruciating pain require more rapid titration to get symptoms under control; these patients may be best Sighing, moaning, groaning managed in an inpatient setting. Dose escalation and drug Grunting, chanting, calling out changes can be safely achieved only when the patient is monitored closely while the steady-state blood level at a given dose is achieved and variations resulting from the patient's clinical status (e.g., state of hydration, serum pro- tein status, renal and hepatic function) are anticipated.46 Rigid, tense body posture, guarding Older patients are generally more susceptible to ad- verse drug reactions. Nevertheless, analgesic and pain- Increased pacing, rocking modulating drugs can be used safely and effectively in this Restricted movement population. It should be assumed that sensitivity to central Gait or mobility changes nervous system active drugs, including opioid analgesics, Changes in interpersonal interactions
increases with age. Age-associated differences in efficacy, Aggressive, combative, resisting care sensitivity, and toxicity should also be expected.21,47 Start Decreased social interactions with the lowest anticipated effective dose, monitor fre- Socially inappropriate, disruptiveWithdrawn quently on the basis of expected absorption and known Changes in activity patters or routines
pharmacokinetics of the agent(s), and then titrate the dose Refusing food, appetite change on the basis of likely steady-state blood levels and clini- Increase in rest periods cally demonstrated effects.12 This process may take 1 to 2 Sleep, rest pattern changes days for some drugs and several days to a week with other Sudden cessation of common routines long-lasting preparations or drugs with very long half- Increased wandering Mental status changes
Greater reductions in pain and improvements in func- tion are usually obtained by combining pharmacologic Increased confusion and nonpharmacologic treatments.45,48 Similarly, the use Irritability or distress of more than one drug to affect a specific therapeutic end-point may be necessary. A combination of two or more Note: Some patients demonstrate little or no specific behavior associated with se-vere pain.
drugs with complementary mechanisms of action may af- Source: AGS Panel on Persistent Pain in Older Persons ford greater relief with less toxicity than would higherdoses of a single agent.12,45 This is particularly true in somepersistent pain syndromes for which no single analgesic C. Reassessment should include evaluation of anal- can produce adequate pain relief without dose-limiting gesic and nonpharmacologic interventions, side side effects. Because of the increasing possibility of drug- effects, and compliance issues. (IIIA) drug and drug-disease interactions in elderly persons with D. Reassessment should consider patient prefer- every additional drug taken, the importance of frequent ences in assessment and treatment revisions.
monitoring cannot be overemphasized. It is especially im- portant for the primary care provider to be aware of allnew drugs, over-the-counter medications, and herbal products added to a patient's regimen by consultants, orthe patient themselves, and to taper and discontinue drugs that do not provide a well-defined therapeutic outcome.
Pharmacotherapy is the most common treatment to In most cases, it makes sense to progress from non- control pain in older patients. All pharmacologic interven- opioid analgesics, such as acetaminophen, to antiinflam- tions carry a balance of benefits and risks. Positive out- matory drugs, neurotransmitter-modulating and mem- comes can be maximized when clinicians become knowl- brane-stabilizing drugs, and opioids, to balance medical edgeable about the pharmacology of the drugs they risks and progressively more severe pain (Table 4).49 The prescribe and regularly monitor their effects. The fre- notable exceptions are inflammatory processes that may quency and duration of follow-up visits for patients with cause severe pain and for which antiinflammatory agents pain should be dictated by each patient's clinical, func- are sufficient. Likewise, certain types of neuropathic pain tional, cognitive, and social circumstances. It is unrealistic may not respond to anything but combinations of non- to imply, or for patients to expect, complete absence of opioid pain-modulating drugs, such as the anticonvul- pain for some persistent pain conditions. Relief can be en- sants. Unless pain is severe, it appears reasonable to start hanced by frequent clinician visits for assurance and vali- with drugs that have the highest likelihood of effecting pain relief with the lowest side-effect profile.
CLINICAL PRACTICE GUIDELINE
JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT CLINICAL PRACTICE GUIDELINE
The Use of Non-Opioid Analgesics
it is incumbent on clinicians to determine that these behav- Most patients with persistent mild to moderate mus- iors do not reflect poorly controlled pain. Longitudinal culoskeletal pain respond favorably to around-the-clock studies increasingly suggest that tolerance (the need for doses of acetaminophen. The maximum recommended more drug in order to get the same therapeutic effect) is dose for patients with normal renal and hepatic function, slow to develop in the face of stable disease.61 Any change and in those with no history of alcohol abuse, is 4,000 mg in a patient's drug requirements signals a need for reas- per day. In patients with renal or hepatic dysfunction or sessment for new or progressing disease before a diagnosis those with hazardous or harmful alcohol use, dose reduc- of "opioid tolerance" is made. Most importantly, con- tion by 50% to 75% or a different therapy is recom- cerns over drug dependency and addiction do not justify mended. In frail older patients, with multiple-system dis- the failure to relieve pain.62 Many state and federal agen- ease, the persistent use of traditional nonselective NSAIDs cies have issued prescribing guidelines or have created pol- is associated with an unacceptable rate of life-threatening icies to support medically indicated use of opioid analge- gastrointestinal bleeding.12,50 Although this risk is reduced sics for patients with pain conditions.63 with the concomitant administration of misoprostol orproton-pump inhibitors,51,52 misoprostol may not be welltolerated by elderly persons.53 Moreover, the cost and in- Opioids of Particular Concern
convenience may not justify these strategies.
It is beyond the scope of this summary to describe in- When maximum safe doses of acetaminophen do not dividual opioid analgesics. However, the panel felt com- adequately control pain, NSAID therapy may be benefi- pelled to review a few of the drugs that clinicians often cial.50,51,54 For patients who require daily persistent therapy question. Propoxyphene has been available for the treat- and who have no specific contraindications, the current ment of mild to moderate pain for many years. Studies evidence, weighing efficacy versus adverse effects, supports suggest that its efficacy is similar to that of aspirin or ace- the use of cyclooxygenase (COX)-2 selective agents.55,56 taminophen alone, but drug accumulation, neuroexcita- The nonacetylated salicylates (e.g., choline magnesium tory effects, and ataxia or dizziness may add unnecessary trisalicylate, salsalate) may provide a relatively safe and morbidity in older patients. Although many practitioners less expensive alternative to the more selective new agents.
and patients continue to find propoxyphene useful, the Although the combination of acetaminophen and an current literature suggests that other analgesic strategies NSAID may be safe, it is unlikely that any net gain in pain are more appropriate for patients with persistent mild to relief is obtained by their combined use. If appreciable re- moderate pain.64-66 duction in symptoms is not experienced within a few days Tramadol is an analgesic with a dual mechanism of of around-the-clock dosing, reevaluation and consider- action: mu opioid-receptor binding combined with inhibi- ation of a different form of drug therapy is indicated. The tion of norepinephrine and serotonin reuptake. It is an un- COX-2 selective drugs are safer than nonselective COX scheduled drug with apparently low abuse and diversion inhibitors in terms of gastrointestinal morbidity and anti- potential.67- 69 Tramadol has been studied largely in mild to platelet effects. However, drug-drug and drug-disease in- moderate pain associated with osteoarthritis, low back teractions associated with COX-2 inhibitors remains a pain, and diabetic neuropathy, and its use in elderly pa- highly active area of research, and clinicians must stay in- tients has been recently reviewed.70, 71-74 Its efficacy and formed about new findings.57-59 In the final analysis, the safety are reported to be similar to those of equianalgesic chronic use of opioids for persistent pain or some other doses of codeine and hydrocodone, including potential for analgesic strategies may have fewer life-threatening risks drowsiness and nausea. Because of the threat of seizures, than does the long-term daily use of high-dose nonselec- rare but potential, tramadol should be used with caution in patients with a history of seizure disorder or those tak-ing other medications that lower seizure thresholds.
Methadone is a potent mu opioid-receptor agonist The Use of Opioid Analgesics
whose use for pain control has waxed and waned. It has The use of opioid analgesics for persistent noncancer regained the interest of pain management clinicians re- pain is becoming more acceptable. Physical dependency is cently because it is thought to be effective for neuropathic an inevitable consequence of continuous exposure to opi- pain and to slow the development of opioid tolerance.75 oids and is managed by gradual dose reduction (tapering) However, methadone is difficult to titrate because of its over the course of several days to weeks if indications for long and variable half-life.76 This property is onerous in opioid therapy no longer exist.60 True addiction (drug older patients with limited reserve and modified hepatic craving and continued use despite known harms) in older metabolism resulting from their use of medications for patients with persistent pain syndromes is probably rare in other persistent conditions. Methadone should be pre- comparison with the known prevalence of undertreated scribed by clinicians who have considerable experience debilitating pain. When aberrant behaviors are observed, with its use or in closely monitored settings.46 Figure 2. Algorithm for the assessment of pain in elderly persons with severe cognitive impairment. (Adapted with permission from
Weiner D, Herr K, Rudy T, eds. Persistent Pain in Older Adults: An Interdisciplinary Guide for Treatment, 2002.)
CLINICAL PRACTICE GUIDELINE
JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT Table 4. Systemic Pharmacotherapy for Persistent Pain Management (oral dosing unless otherwise specified)
Usual Effective Dose
after 4–6 doses Reduce maximum dose 50%– 75% in patients with hepatic insufficiency; hx of alcohol abuse Choline magnesium 500–750 mg q 8 h 2,000–3,000 mg/24 h after 4–6 doses Long half-life may allow qd or bid dosing after steady state is (Tricosal, Trilisate) 500–750 mg q 12 h 1,500–3,000 mg/24 h after 4–6 doses In frail patients or those with (e.g., Disalcid, diminished hepatic or renal Mono-Gesic, Salflex) function, it may be important to check salicylate levels during dose titration and after reaching steady state Celecoxib (Celebrex) Higher doses may be associated with a higher incidence of GI side effects; patients with indications for cardio-protective ASA require aspirin supplement Rofecoxib (Vioxx) Higher doses may be associated with a higher incidence of GI side effects; patients with indications for cardio-protective ASA require aspirin supplement after 2–3 doses Use lowest possible dose to prevent chronic steroid effects; (e.g., Deltasone, anticipate fluid retention and Significant risk of adverse effects in older patients; anticholinergic desipramine (Norpramin), nortriptyline (Aventyl, Pamelor) 800–1,200 mg/24 h Monitor LFTs, CBC, BUN/Creat., 0.05–0.2 mg/kg/day Monitor sedation, memory, CBC Monitor sedation, ataxia, edema Avoid use in patients with conduction block, bradyarrhythmia; monitor ECG Monitor muscle weakness, urinary function; avoid abrupt discontinuation because of CNS irritability JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT CLINICAL PRACTICE GUIDELINE
Table 4. Continued
Usual Effective Dose
after 4–6 doses Mixed opioid and central neurotransmitter mechanism of action; monitor for opioid side effects, including drowsiness and nausea after 3–4 doses Useful for acute recurrent, (e.g., Lorcet, Lortab, episodic, or breakthrough Vicodin, Vicoprofen) pain; daily dose limited byfixed-dose combinations with acetaminophen or NSAIDs after 3–4 doses Useful for acute recurrent, immediate release episodic, or breakthrough pain; daily dose limited by fixed-dose combinations with acetaminophen or NSAIDs Usually started after initial dose sustained release determined by effects of immediate-release opioid 2.5–10 mg q 4 h after 1–2 doses Oral liquid concentrate immediate release recommended for breakthrough (e.g., MSIR, Roxanol) Usually started after initial dose sustained release determined by effects of (e.g., MSContin, Kadian) immediate-release opioid; toxic metabolites of morphine may limit usefulness in patients with renal insufficiency or when high-dose therapy is required; continuous-release formulations may require more frequent dosing if end-of-dose failure occurs regularly after 3–4 doses For breakthrough pain or for (Dilaudid, Hydrostat) around-the-clock dosing; a sustained-release formulation is currently under FDA review after 2–3 patch Usually started after initial dose determined by effects of immediate-release opioid; currently available lowest dose patch (25 g/h) recommended for patients who require 60 mg per 24-h oral morphine equivalents; peak effects of first dose takes 18–24 h. Duration of effect is usually 3 days, but may range from 48 h to 96 h Note: ASA  acetylsalicylic acid; BUN  blood urea nitrogen; CBC  complete blood cell count; CNS  central nervous system; Creat.  serum creatinine; CV  car-diovascular; ECG  electrocardiogram; FDA  U.S. Food and Drug Administration; GI  gastrointestinal; hx  history; LFT  liver function test; NA  not applicable;NSAIDs  nonsteroidal antiinflammatory drugs; hsbedtime; qddaily; bidtwice daily; tidthree times daily.
* Amitriptyline is not recommended.
CLINICAL PRACTICE GUIDELINE
JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT Management of Side Effects
have given informed consent, understand that they may be Monitoring the side effects of opioid therapy should receiving a placebo as a part of the research design, and in- focus on neurologic, gastrointestinal, and cognitive-behav- cur an overall risk of no treatment that is considered very ioral effects. These include gait disturbance (ataxia), dizzi- low.90 In research, placebos help identify and measure ran- ness, falls, pruritus, constipation,77,78 abdominal distention dom or uncontrollable events that may confound results of or discomfort, nausea, sedation, and impaired concentra- some research designs. In clinical settings placebo effects tion. It is advisable to allow several days at the mainte- are common, but they are neither diagnostic of pain or in- nance analgesic dose before advising the patient to resume dicative of a therapeutic response. The effects of placebos driving. Serious side effects, such as myoclonus, impaired are short lived, and most patients eventually learn the consciousness or delirium, and hypoxia or life-threatening truth, resulting in loss of patient trust and more needless respiratory depression, are rare, especially when doses are started low and escalated slowly, allowing for steady-stateblood levels to be reached at each dose prescribed.46 Pa-tients with borderline mobility capabilities and a propen- sity for falls must be monitored carefully for increasing The timing of medications is important. For continu- gait and balance disturbances.79 These patients may re- ous pain, medications are best given on a time-contingent quire evaluation for an assistive device or physical therapy around-the-clock basis.45 Supplemental doses of immedi- throughout the titration phase. Sustained-release opioid ate-release, short-acting analgesics may be required just formulations are available for continuous treatment of before a patient engages in activities known to exacerbate moderate to severe pain.80-84 Patients should be warned pain. Persistent pain is an exhausting experience; decondi- that chewing or crushing continuous-release tablets de- tioning, sleep deprivation, and poor nutrition commonly stroys their controlled-release properties and causes rapid result from unrelieved pain. Most patients will cope better absorption of the entire dose, which may result in over- if drugs are prescribed in an effort to support exercise, en- joyable activities, and a good night's sleep.12 Patients withprimary sleep disturbance and persistent pain require ther- The Use of Adjuvant Drugs
apy directed at both disorders, since each exacerbates the A number of drugs developed for purposes other than other. Sleep deprivation is so common with persistent pain analgesic nevertheless alter, attenuate, or modulate pain that when pain is relieved, there is often a short period, perception. The term adjuvant drug has been used in the lasting a few days, when the patient seems to sleep contin- cancer pain literature to describe them.
uously. This phase of restorative sleep is healthy, as long 85 These drugs may be used alone or in combination with non-opioid or opi- as the patient can be easily aroused and can function to oid analgesics to treat many different persistent pain con- eat, drink, and perform normal toileting. Over the course ditions, especially neuropathic pain. These drugs act on of a few days, once dose stabilization has occurred and the the nervous system through interactions at cell surface re- patient has become rested, sedation should diminish. If ceptor sites or membrane ion channels, or by alteration of not, dose reduction is in order.
synaptic neurotransmitter levels. Recent improvements in Drug regimens for the older patient should be simpli- treatment of depression have been seen with the introduc- fied as much as possible, and regimens should be adjusted tion of selective serotonin-reuptake inhibitor (SSRI) drugs to meet individual needs and life styles.10 Tools to enhance that have relatively low side-effect profiles. It is important compliance should be used whenever possible. Economic to note that SSRI drugs have not been very effective issues do play a role in pain management and should also against pain. Traditional antidepressants that have dem- enter into the decision-making processes once sound prin- onstrated dual effects on pain and depression, such as am- ciples of assessment and treatment have been followed.
itriptyline, nortriptyline, and desipramine, often demon- Clinicians should be aware of common economic barriers, strate unacceptable side effects in elderly persons.
including the lack of Medicare reimbursement for outpa- Gabapentin or other new anticonvulsant drugs with rela- tient oral medications, limited formularies, and delays tively low side-effect profiles may provide a better choice from mail-order pharmacies in some managed-care pro- than older tricyclic antidepressants.
grams. Inner-city areas may not have pharmacies that are It is important to note that all of the currently avail- willing to carry certain opioid analgesics.91 able pain-modulating drugs, including antidepressants, an-ticonvulsants, antispasmodics, antiarrhythmics, and local anesthetics, have side effects that require careful titration, (quality and strength of evidence ratings follow each frequent monitoring until steady-state maintenance levels recommendation: see Table 1) are achieved, and regular follow-up visits to assess thera- I. All older patients with functional impairment or di- peutic and adverse effects.
minished quality of life as a result of persistent painare candidates for pharmacologic therapy. (IA) The Use of Placebos
II. There is no role for placebos in the assessment or The use of placebos in clinical practice is unethical, management of pain. (IC) and there is no place for their use in the management of III. The least toxic means of achieving systemic pain re- persistent pain.89 Placebos, in the form of inert oral medi- lief should be used. When systemic medications are cations, sham injections, or other fraudulent procedures indicated, the noninvasive route should be consid- are justified only in certain research designs where patients ered first. (IIIA) JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT CLINICAL PRACTICE GUIDELINE
IV. Acetaminophen should be the first drug to consider e. Exercise, ambulation, regular toileting in the treatment of mild to moderate pain of muscu- habits and patterns, and physical activity loskeletal origin. (IB) should be encouraged. (IIIB) V. Traditional (nonselective) NSAIDs should be f. If fecal impaction is present, it should be avoided in treating patients who require long-term relieved by enema or manual removal.
daily analgesic therapy. The COX-2 selective agents or nonacetylated salicylates are preferred for older g. A stimulant (e.g., senna) should be pre- persons who require NSAIDs. (IA) scribed to provide regular evacuation.
VI. Opioid analgesic drugs may help relieve moderate to Doses of this agent need to be titrated severe pain, especially nociceptive pain. (IA) against desired effect. (IIB) A. Opioids for episodic (noncontinuous) pain h. Stimulant laxatives are contraindicated should be prescribed as needed, rather than when signs or symptoms of bowel obstruc- around the clock. (IA) tion are present. (IIIA) B. Long-acting or sustained-release analgesic prepa- 4. Mild sedation and impaired cognitive perfor- rations should be used for continuous pain. (IA) mance should be anticipated when opioid an- 1. Breakthrough pain should be identified and algesic drugs are initiated or escalated. Until treated by the use of fast-onset, short-acting these side effects cease: (IIIC) preparations. There are three types of break- a. Patients should be instructed not to drive.
through pain: (IA) a. End-of-dose failure is the result of de- b. Patients and caregivers should be cau- creased blood levels of analgesic with con- tioned about the potential for falls and ac- comitant increase in pain before the next cidents; appropriate precautions should be scheduled dose. If this occurs routinely, consider decreasing the interval between c. Monitoring for profound sedation, uncon- doses of continuous-release agents. In- sciousness, or respiratory depression (de- creasing the dose of the continuous-release fined as a respiratory rate of  8 per agent is another consideration, but this minute or oxygen saturation  90%) may cause undesirable effects, such as se- should occur during rapid, high-dose esca- lations. Naloxone should be used very b. Incident pain is usually caused by activity carefully, titrated in low incremental that can be anticipated and pretreated. (IB) doses, to avoid abrupt, complete opioid c. Spontaneous pain, common with neuro- antagonism and the precipitation of auto- pathic pain, is commonly fleeting and dif- nomic crisis. (IA) ficult to predict. (IC) 5. Patients who experience unremitting opioid- 2. Titration should be conducted carefully. (IA) induced sedation or fatigue that limits quality a. Titration of the maintenance dose should of life or dose escalation to provide optimum be based on the persistent need for and use pain control may require switching to an al- of medications for breakthrough pain. (IA) ternate opioid, or they may be candidates for b. Titration should be based on the pharma- opioid rotation or use of short-term, low-dose cokinetics and pharmacodynamics of spe- psychostimulant therapy (e.g., methylpheni- cific drugs in the older person, the propen- date), or both. (IB) sity for drug accumulation, interactions 6. Severe or persistent nausea may need to be with other drugs, and each patient's treated with anti-emetic medications, as unique clinical and social circumstances.
a. Mild nausea usually resolves spontane- c. The potential adverse effects of opioid an- ously in a few days. (IIIB) algesic medication should be anticipated b. If nausea persists, a trial of an alternative and prevented or treated promptly. (IIA) opioid may be appropriate.(IIIB) 3. Constipation and opioid-related gastrointesti- c. Anti-emetic drugs should be chosen from nal symptoms should be prevented. (IA) those with the lowest side-effect profiles in a. Assessment of bowel function should be older persons. (IIIA) part of the initial assessment and of every VII. Fixed-dose combinations of opioid with acetami- follow-up visit for all patients receiving nophen or NSAIDs may be useful for mild to moder- b. A prophylactic bowel regimen should be A. The maximum recommended dose should not be initiated with the commencement of per- exceeded, to minimize acetaminophen or NSAID sistent opioid therapy. (IA) c. Bulking agents should be used cautiously B. If a maximum safe (nontoxic) dose is reached in patients who are immobile and where without sufficient pain relief because of limits adequate hydration is questionable. (IIIB) imposed by the maximum safe acetaminophen or d. Adequate fluid intake should be encour- NSAID dose, switching to noncombination prep- arations is recommended. (IA) CLINICAL PRACTICE GUIDELINE
JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT VIII. Patients taking analgesic medications should be X. Clinical endpoints should be decreased pain, in- monitored closely. (IA) creased function, and improvements in mood and A. Patients should be reevaluated frequently for sleep, not decreased drug dose. (IIIB) drug efficacy and side effects during initiation, ti-tration, or any change in dose of analgesic medi- B. Patients should be reevaluated regularly for drug efficacy and side effects throughout long-term A variety of nonpharmacologic interventions for per- analgesic drug maintenance. (IIIA) sistent pain have been shown to work alone or in com- 1. Patients on long-term opioid therapy should bination with appropriate pharmacologic strategies.45 be evaluated periodically for inappropriate or Nonpharmacologic pain management interventions in- dangerous drug-use patterns. (IIIA) clude a number of physical and psychologic treatment mo- a. The clinician should watch for indications dalities that often require active participation. Active pa- of the use of medications prescribed for tient involvement helps to build self-reliance and control other persons or of illicit drug use (the lat- over pain. These interventions (e.g., patient education, ter being very rare in this population).
plans for safe physical exercise maintenance, and appro- priate use of self-help techniques) should be an integral b. The clinician should ask about prescrip- part of the approach to management of any persistent pain tions for opioids from other physicians.
The importance of patient education cannot be over- c. The clinician should watch for signs of opi- emphasized. Studies have shown that patient education oid use for inappropriate indications (e.g., programs alone (especially these associated with actual anxiety, depression, grief, loss). (IIIA) practice of self-management and coping strategies) signifi- d. Requests for early refills should include cantly improve overall pain management.92-98 Such pro- evaluation of tolerance, progressive dis- grams commonly include information about the nature of ease, inappropriate behavior, or drug di- pain and how to use pain assessment instruments, medica- version by others. (IIIA) tions, and nonpharmacologic pain management strategies.
e. These evaluations need to take place with For many older persons, family caregiver education is also the same medical equanimity accompany- essential. Whether the program is conducted one-on-one ing similar evaluations for long-term man- or organized in groups, it should be modified to patients' agement of other potentially risky medica- needs and levels of understanding. Suitable written materi- tions (i.e., antihypertensive medications) in als (accommodating for visual impairment) and appropri- order not to burden the patient with exces- ate methods for reinforcement of self-help efforts are im- sive worry or unnecessary fears, or to pro- portant to the success of the program. The clinician should mote "opiophobia." (IIIA) be aware that many patients obtain medical information f. The use of a written "medication agree- from the Internet or other sources, and some of it is mis- ment" is advised when there are concerns leading and possibly dangerous.99 The sources of the pa- about appropriate use or adherence to the tient's information should always be ascertained.
plan of care. (IIIC) Many older persons with persistent pain problems ex- 2. Patients on long-term NSAIDs should be peri- perience significant symptoms of depression and anxiety at odically assessed for symptoms or signs of some time. These symptoms make assessment and treat- gastrointestinal blood loss, renal insuffi- ment more difficult. Depression and anxiety need to be an- ciency, edema, hypertension, and drug-drug ticipated and treated in tandem with other strategies to or drug-disease interactions. (IA) make overall pain management more effective. It is impor- IX. Non-opioid analgesic medications may be appropri- tant to recognize that treatment of anxiety and depressive ate for some patients with neuropathic pain and symptoms is not a substitute for other analgesic strategies, some other persistent pain conditions. (IA) and vice versa. Older persons who have significant anxiety A. Agents with the lowest side-effect profiles should or depression associated with persistent pain often require be chosen preferentially. Patients with intact skin an interdisciplinary and multi-modal approach to the who have localized or regional pain syndromes management of these complex problems.
(e.g., post-herpetic neuralgia) may benefit from Learning cognitive and behavioral pain coping strate- commercially available topical therapies (e.g., gies is an important part of pain management for all pa- capsaicin cream, lidocaine patch). (IB) tients with persistent pain. Cognitive coping strategies are B. Agents may be used alone but often are more designed to modify factors such as helplessness, low self- helpful when used in combination and to aug- efficacy, and catastrophizing that have been shown to in- ment other pain management strategies. (IIB) crease pain and disability.100, 101 Cognitive strategies may C. Therapy should begin with the lowest possible include distraction methods to divert attention from pain doses and increased slowly because of the poten- (e.g., imagery, focal point, counting methods), mindful- tial for toxicity of many agents. (IA) ness methods to enhance acceptance of pain (e.g., medita- D. Patients should be closely monitored for side ef- tion), and methods for altering self-defeating thought pat- terns that contribute to pain and psychologic distress (e.g., JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT CLINICAL PRACTICE GUIDELINE
altering underlying beliefs and attitudes). Behavioral strat- tient's comorbidities, medications, and physical impair- egies can help patients to control pain by pacing their ac- ments is essential to the development of an exercise pre- tivities, increasing their involvement in pleasurable activi- scription that is safe and meets each patient's needs.
ties, and using relaxation methods. Cognitive strategies are Because moderate levels of physical activity should be typically combined with behavioral strategies, and to- maintained indefinitely, each exercise program should be gether they are known as cognitive-behavioral therapy.
adjusted to the preferences of the patient to promote long- The most effective forms of cognitive-behavioral therapy term compliance. A variety of such programs are available use a structured, systematic approach to teaching coping through the Arthritis Foundation,121 and at least one study skills.102 Cognitive-behavioral therapy can be used alone, has shown that water exercises are safe and may have but typically it is combined with pharmacologic therapies.
higher compliance.122 An effective combination of non- Effective programs can be conducted with patients individ- pharmacologic interventions commonly improves the ther- ually or in groups; evidence suggests that the active in- apeutic effects of medications and may facilitate lower volvement of a spouse or significant other enhances the ef- drug dosages.
fects.103,104 Cognitive-behavioral therapy usually requires Unrelieved persistent pain commonly causes patients six to 10 sessions (60 to 90 minutes per session) with a to seek relief with alternative medicine, including homeo- trained therapist. Although such therapy may not be ap- pathy, naturopathy, chiropractic, and spiritual healing. Al- propriate for patients with appreciable cognitive impair- though there is little scientific evidence for the efficacy of ment, the favorable results of controlled trials support its most of these strategies for controlling persistent pain, it is use for many older adults with persistent pain.
important that clinicians not leave patients with a sense of Successful aging amounts to sustaining a high quality hopelessness as a result of their efforts to discourage unap- of life, which primarily means maintaining functional in- proved but benign therapies or to debunk healthcare dependence.105,106 Persistent pain may directly influence quackery and fraud. A recent rising interest in religion and the development and course of disability that threatens spirituality has caused many to seek relief with spiritual functional independence by provoking or worsening phys- healing. Studies suggest that it is helpful to some suffering ical inactivity, which itself is a risk factor for many health from an idiopathic persistent pain syndrome. 123 problems.107,108 Moreover, the resulting deconditioning The personal attention and physical touching pro- may contribute further to both persistent pain and disabil- vided by practitioners of these alternative therapies may ity. The combination of persistent pain, deconditioning, give some modicum of relief to patients with persistent and age-related changes in several physiologic domains pain. Until more rigorous investigation, it is difficult to can make attempts at resuming physical activity and re- make specific recommendations about the long-term use storing functional independence even more painful. Re- of complementary and alternative therapies.
versing the adverse consequences of deconditioning andoptimizing function by increasing physical activity thushas the potential to substantially enhance the older per-son's quality of life.109,110 Strong evidence indicates that regular participation in (quality and strength of evidence ratings follow each physical activities may help control persistent diseases and recommendation: see Table 1) lessen the clinical impact of the biologic changes of ag- I. A physical activity program should be considered for ing.111-115 Furthermore, systematic reviews of observational all older patients. (IA) and randomized controlled clinical trials conclude that A. Physical activities should be individualized to meet there is strong evidence that participation in regular physi- the needs and preferences of each patient. (IA) cal activity reduces the pain and enhances the functional B. For some older adults with severe physical im- capacity of older adults with persistent pain.116-119 Because pairments, a trial of supervised rehabilitation persistent pain is commonly associated with prolonged therapy is appropriate, with goals to improve physical inactivity, these effects may be partly due to the joint range of motion and to reverse specific reversal of the physiologic consequences of decondition- muscle weakness or other physical impairments ing. In addition, increasing physical activity may improve associated with persistent pain. (IA) psychologic health, and regular participation in physical C. For healthy individuals who are currently seden- activities may lessen the clinical impact of age-related bio- tary or deconditioned, referral should be made to a logic changes and of chronic diseases.107,109 group exercise program (e.g., YMCA classes) for a A variety of therapeutic exercise programs have been moderate program of physical activity. (IIIC) used to treat persistent pain associated with a range of D. For those who are incapable of strenuous train- conditions.116,117,120 Components of an exercise prescrip- ing, initial training should be conducted over 8 tion appropriate for the older adult have been described in to 12 weeks and should be supervised by a pro- a recent AGS Practice Recommendation.120 The primary fessional with knowledge of the special needs of objectives of such an exercise program are to reduce pain older adults. (IA) and to reverse the physical impairments and the conse- II. Moderate levels of physical activity (leisure-time or quences of deconditioning. A program should include ex- utilitarian) should be maintained. (IIIC) ercises that improve joint range of motion, increase muscle III. Any physical activity program for older patients strength and power, enhance postural and gait stability, should include exercises that improve flexibility, and restore cardiovascular fitness. An inventory of the pa- strength, and endurance. (IA) CLINICAL PRACTICE GUIDELINE
JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT IV. Patient education programs are integral components improve appropriate referrals, and share the responsibility of the management of persistent pain syndromes. (IA) for the care of elderly patients with persistent pain. Refo- A. Content should include information about self- cusing not only the curricula for trainees but also continu- help techniques (e.g., relaxation, distraction), the ing education for practitioners is the key to assuring opti- known causes of their pain, the goals of treat- mum care for older adults. Using such education as an ment, treatment options, expectations of pain indicator of quality by healthcare organizations and ac- management, and analgesic drug use. (IIA) creditation bodies will serve to more fully integrate the B. Educational content and the patient's self-help principles of pain management into clinical practice. Like- efforts should be reinforced during every patient wise, empowering consumers with an appreciation of the encounter. (IIIA) principles of pain management will create an advocacy for C. Focused patient education should be provided standards by which all providers will eventually be mea- prior to special treatments or procedures. (IIIC) D. Patients should be encouraged to educate them- Today, financial considerations are a part of every selves by using available local resources (e.g., lo- healthcare decision. Insurance companies, managed-care cal hospitals, support groups, and disease-spe- plans, and federal and state health agencies should recog- cific organizations). (IIIC) nize the importance of pain management. Adequate reim- V. Formal cognitive-behavioral therapies are helpful for bursement should be provided for those services that ensure many older adults with persistent pain. (IA) comfort, rehabilitation, and, especially for those near the A. Cognitive-behavioral therapy conducted by a end of life, palliative care. Third-party payers need to con- professional should be applied as a structured sider carefully the financial incentives they create. Policies program that includes education, a rationale for that seem financially beneficial in the short term may result therapy, training in cognitive and behavioral in needless disability, suffering, and increased healthcare pain coping skills, methods to generalize coping utilization in the long run. Care must be taken not to create skills, and relapse prevention. (IIIA) incentives that promote unjustified use of more costly and B. Plans for coping with pain exacerbations should oftentimes unnecessarily interventional therapies.12 be a part of this therapy to prevent self-defeatingbehavior during such episodes. (IIIC) C. Spouses or other partners can be involved in cog- nitive-behavioral therapy. (IA) (quality and strength of evidence ratings follow each VI. Other modalities (e.g., heat, cold, massage, liniments, recommendation: see Table 1) chiropractic, acupuncture, and transcutaneous elec- I. Healthcare facilities should support policies and pro- trical nerve stimulation) often offer temporary relief cedures for routine screening, assessment, and treat- and can be used as adjunctive therapies. (IIIC) ment of persistent pain among all older patients.
Health organizations should include pain manage- RECOMMENDATIONS FOR HEALTH SYSTEMS
ment as a major domain in the development of clini- THAT CARE FOR OLDER PERSONS
cal pathways. (IIB) II. Attention should be devoted to pain across the con- tinuum of care and should not be limited to those The healthcare system has an obligation to provide patients who are near the end of life. (IIB) comfort and pain management for older patients. Health- III. Ambulatory care facilities, hospitals, nursing homes, care facilities, quality review organizations, and govern- assisted-living facilities, and home-care agencies ment regulatory agencies should work together to facili- should routinely conduct quality assurance and tate structures and processes that ensure access and the quality improvement (QA and QI) activities in pain delivery of quality pain management services.124 In some management. (IIB) cases, organizations need to revise regulations that have A. QA and QI activities should include appropriate created barriers to effective pain management. Medical li- structure and process indicators of pain assess- cense boards and law enforcement agencies, in their efforts ment and treatment activities. (IIIC) to reduce illicit drug use, should recognize their equal obli- B. Benchmarks for quality improvement should be gation to ensure the easy availability of safe and effective established internally and should include quanti- pain medications (i.e., opioid analgesic drugs) for those fiable pain outcomes, which may include, but with legitimate medical needs. In all cases, clinicians and should not be limited to, patient satisfaction.
professional organizations need to work with legislative bodies to promote appropriate legislation.12,125,126 IV. Healthcare financing systems (third-party payers, Traditionally, healthcare professionals have not been managed-care organizations, and publicly financed adequately trained in pain assessment and management.
programs) should extend resources for persistent This lack of sensitivity to the problem of pain and its se- pain management. (IIIC) quelae has contributed to both underrecognition and un- A. Present diagnosis-driven reimbursement systems dertreatment of pain in older adults. Progress has been should be revised to improve incentives for time- limited by a lack of professional attention to the interdisci- consuming pain management. (IIIC) plinary model critical to the effective care of older adults.
1. The safest and most effective pharmacologic Primary care physicians need to work with pain specialists and nonpharmacologic strategies for pain and palliative care providers to enhance communication, management should be provided. (IIIC) JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT CLINICAL PRACTICE GUIDELINE
2. Reimbursement systems must not result in the that has become a major barrier to the prescrip- inaccessibility of effective treatment or in tion of effective pain medications. (IIIC) needless suffering. (IIIC) C. Law and drug enforcement agencies should rec- 3. Reimbursement systems should promote ade- ognize their role in facilitating and providing quate compensation for all providers who can easy access to the legitimate use of controlled contribute to effective pain management (e.g., substances by patients in pain. (IIIC) physical therapy, nursing, psychology, social D. Law and drug enforcement agencies should pub- work, occupational therapy). (IIIC) lish information for clinicians and the public re- B. Reimbursement should be appropriate for the in- garding the legal and illegal prescribing, as well creased time and resources often necessary for as the dispensing, storage, disposal, and use of the care of frail, dependent, and disabled older controlled substances for pain management.
patients in all settings. (IIIC) V. Health systems (especially integrated networks and community health planners) should ensure accessi- Panel Members & Affiliations
bility to specialty pain services. (IB) The American Geriatrics Society (AGS) Panel on Per- VI. Specialty pain services should be accredited and ad- sistent Pain in Older Persons includes: Bruce Ferrell, MD here to guidelines defined by quality review organi- (Chairman): UCLA School of Medicine, Los Angeles, CA; David Casarett, MD: Center for Health Equity Research A. Services should include medicine, pharmacy, and Promotion, Philadelphia VA Medical Center, Phila- mental health, nursing, physical therapy, and oc- delphia PA; Jerome Epplin, MD: Litchfield Family Practice cupational therapy. (IIIC) Center, Litchfield, IL; Perry Fine, MD: University of Utah B. These services should also be available outside a Pain Management Center, Salt Lake City, UT; F. Michael coordinated multidisciplinary pain service. (IIIC) Gloth, III, MD: Victory Springs Senior Health Associates VII. Education in pain management for all healthcare & John Hopkins University School of Medicine, Balti- professionals should be improved at all levels. (IB) more, MD; Keela Herr, PhD, RN: University of Iowa, Iowa A. Professional curricula should provide substantial City, IA; Paul Katz, MD: University of Rochester Medical training and experience in pain management for School, Rochester, NY; Francis Keefe, PhD: Duke Medical older adults. (IIIC) Center, Durham, NC; Peter J.S. Koo, PharmD: University 1. Curricula should adhere to published general of California, San Francisco, CA; Michael O'Grady, MD: curriculum guidelines until those specific to Emory University School of Medicine, Atlanta, GA; Peggy older adults have been developed (e.g., those Szwabo, PhD, LCSW, RN: Saint Louis University, Saint of the International Association for the Study Louis, MO; April Hazard Vallerand, PhD, RN: Wayne State University, Detroit, MI; Debra Weiner, MD: Univer- 2. Trainees should demonstrate proficiency in sity of Pittsburgh School of Medicine/ Pain Evaluation and pain assessment and management. (IIIC) Treatment Institute, Pittsburgh, PA.
B. Health systems should provide continuing educa- tion in pain assessment and management to health professionals at all levels. (IB) C. Accreditation bodies should include pain man- Research services were provided by Sue Radcliff, Indepen- agement curriculum content as evaluation crite- dent Researcher, Denver CO. Editorial services were pro- vided by Barbara B. Reitt, PhD, ELS(D), Reitt Editing VIII. Pain management should be included in consumer Services, Highlands, NC. Additional research and admin- information services. (IIIB) istrative support provided by Elvy Ickowicz, MPH, and A. Healthcare systems should encourage patients Nancy Lundebjerg, MPA, Department of Professional Ed- and their surrogates to advocate for more effec- ucation and Special Projects, American Geriatrics Society, tive pain management. (IIIC) New York, NY.
B. Healthcare systems should provide educational materials (posters, pamphlets, Internet resources) Peer Review
that encourage patients to discuss pain with their The following organizations with special interest and providers. (IIIC) expertise in the management of pain in older persons pro- IX. Programs and regulations designed to decrease illicit vided peer review of a preliminary draft of this guideline: drug use should be revised to eliminate barriers to American Academy of Family Physicians; American Acad- persistent pain management for the older patient.
emy of Home Care Physicians; American Academy of Or- thopaedic Surgeons; American Academy of Pain Medicine; A. State license boards should publish professional American Academy of Physical Therapy; American Acad- standards or guidelines for prescribing controlled emy of Physical Medicine and Rehabilitation; American substances for pain, including professional stan- College of Clinical Pharmacy; American Medical Associa- dards for chronic use, expectations for medical tion; American Occupational Therapy Association; Ameri- record documentation, and standards for profes- can Society of Anesthesiologists; American Society of Clin- sional conduct review. (IIIC) ical Oncologists; American Society of Consultant B. State medical license boards must work to elimi- Pharmacists; Hospice and Palliative Nurses Association; nate clinicians' trepidation over conduct review Oncology Nursing Society.
CLINICAL PRACTICE GUIDELINE
JUNE 2002–VOL. 50, NO. 6, SUPPLEMENT 7. Cooner E, Amorosi S. The Study of Pain in Older Americans. New York: Louis Harris and Associates, 1997.
Dr. Ferrell is a member of the speaker's bureau for 8. Blyth FM, March LM, Brnabic AJ, et al. Chronic pain in Australia: a prev- Purdue Pharma; Dr. Fine is a member of the speaker's bu- alence study. Pain 2001;89:127-134.
reau for Merck, Janssen, Purdue Pharma, Cephalon and 9. Mantyselka P, Kumpusalo E, Ahonen R, et al. Pain as a reason to visit the Orthobiotech; Dr. Casarett has received research support doctor: a study in Finnish primary health care. Pain 2001;89:175-180.
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