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Common Pain Syndromes in Older Adults Paul J. Christo, MD, MBA


Disclosure Consultant/Independent Contractor: Ameritox, Actavis, Chattem, Inc., Quadrant HealthCom Inc., Perrigo Company Grant/Research Support: Medtronic


Learning Objectives Recognize age-associated changes in pain processing and pain threshold Identify four common pain syndromes of older adulthood Describe one treatment for each of the common pain syndromes


Overview of Aging & Pain  By 2050, number of older persons globally will exceed number of young for first time in history  Number of older adults > 60 yrs will increase from 1/10 to 1/5 by 2050  Chronic conditions, especially pain will increase in prevalence as population ages  Variety of physiological, anatomical, psychosocial changes occur and attitudes toward pain impact these changes Winker MA and DeAngelis CD. Caring for an Aging Population Call for Papers. JAMA. 2010; 303:455-6


Overview of Aging & Pain (cont’d)  Chronologic markers for “old age” arbitrary  Federal government uses age 65 years as benchmark  Gerontologists focus on persons aged 60 years and older  Researchers identify 3 major subgroups –younger old: age 65-74 years –older old: age 75-84 years –oldest old: age 85+ years American Psychological Association. Available at: http://www.apa.org/pi/aging/practitioners/why.html.


Normal Aging Loss of brain volume Neuronal death and gliosis Senile neuritic plaques and neurofibrillary tangles without cognitive impairment Morphological changes associated with decrements in neuropsychological performance But, chronic pain is not a normal aspect of aging Bennett et al; Neurology 2006; 66: 1837 Knopman et al; J Neuropath Exp Neurol 2003; 62: 1087 Hulette CM et al; J Neuropath Exp Neurol 1998; 57: 1168


Prevalence of Pain in Older Adults As many as 80% of older nursing home patients suffer from significant pain Persistent pain ranges from 25% to 50% in older adults1 and ↑ with age2 20% of adults age ≥65 years admit to day-long periods of pain in past month, and nearly 60% report pain persisted for ≥1 year AGS Panel on Persistent Pain in Older Persons. J Am Geriatr Soc. 2002;50(6 Suppl):S205-S224. Helme RD et al. Clin Geriatr Med. 2001;17(3):417-432. CDC. Health, United States, 2006. Available at: www.cdc.gov/nchs/hus/hus6.pdf.htm.


Prevalence of Pain in Older Adults (cont’d) Age > 60, twice as likely to have persistent pain than younger counterparts Age = 80, three times more likely to have persistent pain than those under 18 years Herr K. Chronic Pain: challenges and assessment strategies. J Gerontol Nurs 2002;28 (1):20-27; quiz 54-55 Weiner D, Peterson B, Keefe F. Chronic pain-associated behaviors in the nursing home: resident versus caregiver perceptions. Pain 1999;80 (3):577-588.


Age-Associated Changes In Pain Processing Decreased density of myelinated and unmyelinated fibers Increased number of damaged or degenerated sensory fibers Nerve conduction velocity somewhat slowed Selective impairment of myelinated nociceptive fiber function and impaired early warning function of nociceptive A (delta) fibers


Age-Associated Changes In Pain Threshold  Inconclusive due to methodological differences  But, supportive evidence that age-related increase in thresholds to thermal, pressure, and electrical stimulation  Pain thresholds directed toward elevation with age  Pain threshold increases, but tolerance to pain decreases

Harkins SW, Price DD, Martelli M. Effects of age on pain perception: thermonociception. J Gerontol 1986;41(1):58-63 Edwards RR. Age-associated differences in pain perception and pain processing. In: Gibson SJ, Weiner DK, eds. Pain in Older Persons. Seattle, IASP Press; 2005:45-65 Gibson SJ, Farrell M. A review of age differences in the neurophysiology of nociception and the perceptual experience of pain. Clin J Pain 2004;20(4): 227-239


Common Painful Disorders Osteoarthritis Low Back Pain Neuropathic Pain: Postherpetic Neuralgia Postoperative Pain Variable epidemiology due to differences in definitions of pain and significant pain, period prevalence Calvalieri TA. Pain management in the elderly. J Am Osteopath Assoc. 2002;102(9):481-485. AGS Panel. Management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(6):s205-s224.


Major Classifications of Pain in Older Adults Nociceptive pain –Visceral or somatic –Occurs from stimulation of pain receptors Examples include: –Inflammatory or traumatic arthritis –Myofascial pain syndromes –Postoperative pain •Typically responds to acetaminophen, NSAIDs, Opioids Calvalieri TA. Pain management in the elderly. J Am Osteopath Assoc. 2002;102(9):481-485. AGS Panel. Management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(6):s205-s224.


Major Classifications of Pain in Older Adults  Neuropathic pain – Pathology of the nervous system – Both peripheral and central sensitization involved; lesion must directly involve nociceptive pathways – Examples: Post-herpetic neuralgia, phantom limb pain, trigeminal neuralgia, post-stroke, thalamic pain – May respond to antidepressants, anticonvulsants, topical local anesthetics, and opioids – Proposed definition: pain arising as a direct consequence of a lesion or disease affecting the somatosensory system Calvalieri TA. Pain management in the elderly. J Am Osteopath Assoc. 2002;102(9):481-485. AGS Panel. Management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(6):s205-s224.


Osteoarthritis Osteoarthritis (OA) –Degenerative joint disease (synovial joints) • Cartilaginous breakdown occurs with metabolically dynamic and reparative processes ensuing • Primary targets: hands, knees, hips, and spinal facet joints • Weight-bearing joints most often affected • Risk Factors: age, occupation (football, ballet, boxing), obesity, genetic Jones A, Doherty M. ABC of rheumatology. Osteoarthritis. BMJ 1995;310:457-60 Dieppe P. Osteoarthritis. A review. J Royal Coll Phys London 1990;24:262-7 Felson DT. Epidemiology of hip and knee osteoarthritis. Epidemiol Rev 1988;10:1-28.


OA: Prevalence 10-20% population Onset: > 50 years Radiographic evidence almost universal > age 65 Knee most affected > age 50; 10% pop Female: male ratio 2-3:1 Bagai T, Jawad A, Kidd B. Chronic Joint Pain. In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS, eds. Chronic Pain. United Kingdom: Hodder Arnold; 2008: 518-536. Scott DL. Osteoarthritis and rheumatoid arthritis. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s Textbook of Pain 5th ed. Philadelphia: Elsevier Churchill Livingstone; 2006: 653-681.


OA: Clinical Features  Pain prime reason for medical care and leading cause of disability in seniors  Progressive loss of articular cartilage leading to joint pain and movement restrictions  Joint pain in one or more joints  Experienced with activity, relieved by rest  Stiffness, swelling, deformity, loss of function  Morning stiffness common, usually for < 1 hr.  If joints become unstable, pain often more prominent, even at rest Steigelfest, E. Osteoarthritis. eMedicine, 2005. Available from www.emedicine.com/med/topic1682.htm Prevalence of disabilities and associated health conditions among adults—United States 1999. MMWR Morb Mortal Wkly Rep 2001;50:120-125.


OA: Evaluation Check for crepitus, bony hypertrophy, warmth, effusion, muscle weakness Radiographic findings (X-ray) –Narrowing joint space, osteophyte formation, subchondral bone sclerosis

Diagnosis supported by x-ray, but H & P more important Scott DL. Osteoarthritis and rheumatoid arthritis. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s Textbook of Pain 5th ed. Philadelphia: Elsevier Churchill Livingstone; 2006: 653-681. Jones A, Doherty M. ABC of rheumatology. Osteoarthritis. BMJ 1995;310:457-60 Steigelfest, E. Osteoarthritis. eMedicine, 2005. Available from www.emedicine.com/med/topic1682.htm


OA: Management  Pharmacologic – Acetaminophen 1000 mg four times daily or less – Low dose, non-steroidal anti-inflammatory drugs (ibuprofen, celecoxib) or nonacetylated salicylates • Lowest dose for shortest duration

– Diclofenac gel 1%: LE or UE joints (FDA Approved) – Diclofenac solution 1.5% for knee OA (40 gtt QID- FDA Approved) – Tramadol Scott DL. Osteoarthritis and rheumatoid arthritis. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s Textbook of – Opioids Pain 5th ed. Philadelphia: Elsevier Churchill Livingstone; 2006: 653-681. Bagai T, Jawad A, Kidd B. Chronic Joint Pain. In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS, eds. Chronic Pain. United Kingdom: Hodder Arnold; 2008: 518-536. – Capsaicin AGS Panel on Persistent Pain in Older Persons. Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc (57) 8:2009 Raynauld JP, Buckland-Wright C, Ward R, et al. Safety and efficacy of long-term intraarticular steroid injections in – Methylsalicylate osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2003;48(2):370-377. Lo GH, LaValley M, McAlindon T, Felson DT. Intra-articular hyaluronic acid in treatment of knee osteoarthritis. JAMA 2003;290:3115-3121


OA: Management  Interventional – Intraarticular corticosteroid injections • Every 3 months for at least 2 years with benefit and no structural change

– Hyaluronic acid injections • Approved for OA of knee • Data suggests small benefit • 3-5 injections

– Surgery: Joint replacement Scott DL. Osteoarthritis and rheumatoid arthritis. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s Textbook of Pain 5th ed. Philadelphia: Elsevier Churchill Livingstone; 2006: 653-681. Bagai T, Jawad A, Kidd B. Chronic Joint Pain. In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS, eds. Chronic Pain. United Kingdom: Hodder Arnold; 2008: 518-536. AGS Panel on Persistent Pain in Older Persons. Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc (57) 8:2009 Raynauld JP, Buckland-Wright C, Ward R, et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2003;48(2):370-377. Lo GH, LaValley M, McAlindon T, Felson DT. Intra-articular hyaluronic acid in treatment of knee osteoarthritis. JAMA 2003;290:3115-3121


OA: Management (cont’d) Physical Modalities  Patient education  Self-management  Support groups  Weight loss  Muscle strengthening  Aerobic conditioning

 Off-Loading -Patellar taping  Assistive devices-Cane  Bracing  Insoles  TENS

Scott DL. Osteoarthritis and rheumatoid arthritis. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s Textbook of Pain 5th ed. Philadelphia: Elsevier Churchill Livingstone; 2006: 653-681. Bagai T, Jawad A, Kidd B. Chronic Joint Pain. In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS, eds. Chronic Pain. United Kingdom: Hodder Arnold; 2008: 518-536.


Low Back Pain (LBP): Overview  Common musculoskeletal disorder in older adults  Often more than one pathological contributor (OA, spinal stenosis, scoliosis, degenerative disc disease, leg length discrepancy, muscular) –but, not all pain-inducing in older adults  36% of older adults experienced LBP during the prior year, and 21% of these report moderate to severe pain occurring very often or more van Tulder M, Koes B. Low back pain. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s Textbook of Pain 5th ed. Philadelphia: Elsevier Churchill Livingstone; 2006: 699-708. Weiner DK et al. For the Health, Aging, and Body Composition Research Group. How does low back pain impact physical function in 2003;4(4):311-320. independent, well-functioning older adults? Evidence from the Health ABC cohort and implications for the future. Pain Med


Low Back Pain: Classification  May be classified temporally –Acute (less than six weeks) –Subacute (between 6 weeks and three months) –Chronic or Persistent (greater than 3 months)  Also classified as non-specific (mechanical- sprain, strain, spondylosis [disc, facet], fx, alignment D/O [kyphosis, scoliosis]), visceral (endometriosis, prostatitis), non-mechanical (neoplasia, infection), inflammatory arthritis (ankylosing spondylitis & Paget's dz) Deyo RA, Weinstein JN. Primary Care: Low back pain. N Engl J Med 2001;344:363 van Tulder M, Koes B. Low back pain. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s Textbook of Pain 5th ed. Philadelphia: Elsevier Churchill Livingstone; 2006: 699-708. Levin KH. Disease Management Project. Low Back Pain. The Cleveland Clinic. 2002


LBP: Classification Majority (at least 90% or more) have mechanical LBP seen in primary care setting –no neoplastic, infectious, inflammatory cause –less than 5% have serious systemic disease

Deyo RA, Weinstein JN. Primary Care: Low back pain. N Engl J Med 2001;344:363 van Tulder MW, Assendfelt WJ, et al. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine 1997;22:427-34.


LBP: Etiology  Herniated disc  Myofascial pain  Spinal stenosis  Lumbar spondylosis  Osteoarthritis root compression  Unknown etiology

 Spondylolisthesis  Discogenic  Facet arthropathy  Lumbar instability  Spondylolysis  Scoliosis  Pain with psych component Cohen SP, Rowlingson J, Abdi S. Low back pain. In: Warfield CA, Bajwa ZH, eds. Principles and Practice of Pain medicine 2nd ed. New York: McGraw-Hill; 2004: 273-284.


LBP: Etiology (cont’d) Compression fracture Sacroiliac joint Epidural fibrosis Epineural fibrosis Arachnoiditis Piriformis

Vertebral osteomyelitis Epidural abscess Discitis Metastatic spinal tumors Failed back surgery Spina bifida Cohen SP, Rowlingson J, Abdi S. Low back pain. In: Warfield CA, Bajwa ZH, eds. Principles and Practice of Pain medicine 2nd ed. New York: McGraw-Hill; 2004: 273-284.


LBP: Clinical Features Pain Muscle tension/stiffness May report radicular symptoms –paresthesias, pain –numbness, weakness

Gait disturbance Reduced muscle strength Malik H, Benzon HT. Low back pain. In: Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, eds. Raj’s Practical Management of Pain 4th ed. Philadelphia: Mosby Elsevier; 2008: 367-387.


LBP: History History – is there evidence of: neurologic compromise, systemic disease, psychosocial stressors? – elements suggestive of underlying systemic disease •age >50, unexplained weight loss, history of malignancy, pain duration more than one month, pain at night, nonresponsive to previous therapies Deyo RA, Weinstein JN. Primary Care: Low back pain. N Engl J Med 2001;344:363.


LBP: Common Disorders in Older Adults  OA: Degenerative disc disease and facet disease nearly universal in 65yrs and older – also consider hip and knee arthritis  Myofascial Pain: trigger points (esp. quadratus lumborum or piriformis), iliotibial band  Sacroiliac joint Syndrome  Fibromyalgia: new diagnostic methods either by direct physician evaluation, or selfreport questionnaire – no tender point exam required. – criteria based on widespread pain index & symptom severity  Osteoporosis: vertebral compression fracture Weiner DK, Cayea D: Low Back Pain and Its Contributors in Older Adults: A Practical Approach to Evaluation and Treatment. In: Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005;35: 329-54. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care Res. 2010;62(5):600-610 Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fribromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR preliminary diagnostic criteria for fibromyalgia. J Rheumatol. 2011;38(6):1113-1122


LBP: Physical Exam ď&#x201A;§ Evaluation includes ROM, spinal palpation, inspection of back and posture, straight leg raise test, neurologic assessment, possible malignancy evaluation (lymph nodes), pain behaviors â&#x20AC;&#x201C;Waddell's signs: multiple signs suggest behavioral component to the pain Shelerud RA. Chronic back pain. In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS, eds. Chronic Pain. United Kingdom: Hodder Arnold; 2008: 501-517.


LBP: Physical Exam (cont’d) In older adults, focus on: – sacroiliac joint (palpation and Patrick’s test), paraspinal muscles, piriformis, iliotibial band, leg length discrepancy – knee and hip motion with possible arthritis leading to worsening SI joint syndrome

Weiner DK, Cayea D: Low Back Pain and Its Contributors in Older Adults: A Practical Approach to Evaluation and Treatment. In: Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005;35: 329-54.


LBP: Imaging  Diagnostic studies usually not recommended for pain less 4-6 weeks (except red flags-serious underlying cause of LBP)  Red Flags: recent trauma, unexplained weight loss or fever, immunosuppression, history of cancer, IV drug use, osteoporosis, age >70, progressive neurologic deficits, duration >6 weeks

American College of Radiology. ACR Appropriateness Criteria. www.acr.org Malik H, Benzon HT. Low back pain. In: Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, eds. Raj’s Practical Management of Pain 4th ed. Philadelphia: Mosby Elsevier; 2008: 367-387.


LBP: Imaging AP and Lateral radiographs – if no clinical improvement in 4-6 weeks –rule out tumor, infection, instability, spondyloarthropathy, spondylolisthesis

MRI/CT – for progressive neurologic deficits, high suspicion of cancer or infection, and for > 12 weeks of LPB Ash LM, Modic MT, et al. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. Am J Neuroradiol 2008;29:1098


LBP: Evaluation  MRI: identifies disc herniation, nerve roots, malignant/inflammatory/vascular disorders  CT: evaluates bony elements of spine  Plain radiography: spine fractures or deformities  CT Myelography: detects lesions of spinal canal, visualizes spinal nerve roots  Electromyography/nerve conduction: if neuroimaging differs from radicular symptoms Malik H, Benzon HT. Low back pain. In: Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, eds. Raj’s Practical Management of Pain 4th ed. Philadelphia: Mosby Elsevier; 2008: 367-387.


LBP: Management  Variable depending on symptoms/chronicity  Conflicting studies - heterogeneity of trials, interventions, comparison, outcome  No clear definitive treatment given multiple manifestations of back pain  Exercise only proven intervention for prevention or recurrence of back pain Malik H, Benzon HT. Low back pain. In: Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, eds. Raj’s Practical Management of Pain 4th ed. Philadelphia: Mosby Elsevier; 2008: 367-387.


LBP: Management  Self-care: maintain activity as tolerated. Minimize bedrest  Physical therapy: some benefit noted in studies  Psycho-educational strategies: cognitive behavioral therapy and multidisciplinary rehabilitation (physical, vocational, behavioral approaches) are effective  Pharmacologic therapies: Acetaminophen, NSAIDS, Tricyclic Antidepressants, Muscle relaxants, Anticonvulsants, Opioids Hagen, KB, Hilde, G, Jamtvedt, G, Winnem, M. Bed rest for acute low-back pain and sciatica. Cochrane Database Syst Rev 2004; :CD001254. Frost, H, Lamb, SE, Doll, HA, et al. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ 2004; 329:708. Ostelo, RW, van Tulder, MW, Vlaeyen, JW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev 2005; :CD002014. Guzman, J, Esmail, R, Karjalainen, K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001; 322:1511.


LBP: Management (Evidence for Efficacy) Acute low back pain

Persistent low back pain

–Stay active –NSAIDS –Muscle relaxants

–Multidisciplinary pain treatment program –Exercise therapy –Behavioral therapy

Malik H, Benzon HT. Low back pain. In: Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, eds. Raj’s Practical Management of Pain 4th ed. Philadelphia: Mosby Elsevier; 2008: 367-387.


LBP: Management  Pharmacologic Therapies – Acetaminophen: effective for LBP – NSAIDS: effective for short term relief of LBP • Avoid indomethacin, ketorolac, naproxen, oxaprozin, piroxicam – Tricyclic Antidepressants: data support use in LBP • Avoid amitriptyline, doxepin – Serotonin norepinephrine reuptake inhibitor: duloxetine – Muscle Relaxants: consider if true painful muscle spasm, short term • Avoid methocarbamol, cyclobenzaprine, carisoprodol, chlorzoxazone AGS Panel on Persistent Pain in Older Persons. Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc (57) 8:2009, 1331-1346. Chou R, Huffman LH. Ann Intern Med. 2007;147:505-514


LBP: Management  Pharmacologic Therapies –Anticonvulsants: Some evidence that gabapentin effective for LBP –Opioids: evidence for effectiveness in LBP •balance harms of unrelieved pain with potential adverse effects of opioids Chou R, Huffman LH. Medications for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 2007;147:505-514. Roelofs, PD, Deyo, RA, Koes, BW, et al. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev 2008; CD000396. Salerno, SM, Browning, R, Jackson, JL. The effect of antidepressant treatment on chronic back pain: a meta-analysis. Arch Intern Med 2002; 162:19. van Tulder, MW, Touray, T, Furlan, AD, et al. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the cochrane collaboration. Spine 2003; 28:1978. McCleane, GJ. Does gabapentin have an analgesic effect on background, movement and referred pain? A randomised, double-blind, placebo controlled study. The Pain Clinic 2001; 13:103. Hale, ME, Dvergsten, C, Gimbel, J. Efficacy and safety of oxymorphone extended release in chronic low back pain: results of a randomized, double-blind, placebo- and active-controlled phase III study. J Pain 2005; 6:21.


Neuropathic Pain: Definitions ď&#x201A;§Pathology of the nervous system. Both peripheral and central sensitization involved. Lesion must involve nociceptive pathways ď&#x201A;§Proposed: pain arising as a direct consequence of a lesion or disease affecting the somatosensory system Campbell JN, Meyer RA. Mechanisms of neuropathic pain. Neuron. 2006 Oct 5;52(1):77-92. Treede RD, Jensen TS, Campbell JN, Cruccu G, Dostrovsky JO, Griffin JW, Hansson P, Hughes R, Nurmikko T, Serra J. Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neurology. 2008 Apr 29;70(18):1630-5.


Neuropathic Pain: Classification Peripheral Neuropathies  Symmetrical (often polyneuropathies)  Metabolic  Nutritional deficiency  Toxic  Immune mediated  Infectious

 Asymmetrical (often focal)  Mononeuritis  Vasculitic  Infectious  Physical injury  Plexus  Radiation induced  Cranial neuralgias

Shenoy R, Roberts K, Anand P. Peripheral neuropathies. In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS, (eds). Chronic Pain. United Kingdom: Hodder Arnold; 2008: 335-351.


Neuropathic Pain: Classification Central Neuropathies Spinal cord injury Central post-stroke pain Multiple sclerosis

Watson JC. Central neuropathic pain: syndromes, pathophysiology, and treatments. In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS, (eds). Chronic Pain. United Kingdom: Hodder Arnold; 2008: 374-387.


Neuropathic Pain: Prevalence Heterogeneous condition, multiple etiologies – affects up to 7%-8% population Common neuropathic pain conditions in older adults –Diabetic peripheral neuropathic (DPN) –Post-herpetic neuralgia (PHN) Torrance N, Smith BH, Bennett MI, Lee AJ (April 2006). The epidemiology of chronic pain of predominantly neuropathic origin. Results from a general population survey. J Pain 7 (4): 281-9. Williams KA, Hurley RW, Lin EE, Wu CL. Neuropathic pain syndromes. In: Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, eds. Raj’s Practical Management of Pain 4th ed. Philadelphia: Mosby Elsevier; 2008: 427-443.


Neuropathic Pain: Mechanisms Peripheral –Neuronal hyperexcitability/dysfunction –Neural degeneration/damage –Idiopathic –Demyelination

Central –Dysfunction of spinal-thalamic-cortical pathways Williams KA, Hurley RW, Lin EE, Wu CL. Neuropathic pain syndromes. In: Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, (eds). Raj’s Practical Management of Pain 4th ed. Philadelphia: Mosby Elsevier; 2008: 427-443. Watson JC. Central neuropathic pain: syndromes, pathophysiology, and treatments. In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS, (eds). Chronic Pain. United Kingdom: Hodder Arnold; 2008: 374-387.


Neuropathic Pain: Clinical Features Widespread pain not otherwise explainable, sensory deficit, burning pain, pain to light touch, pain attacks without provocation Descriptions: pins, needles, stabbing, electric-like, bandlike sensations, painful numbness, burning Allodynia Hyperalgesia Shenoy R, Roberts K, Anand P. Peripheral neuropathies. In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS, eds. Chronic Pain. United Kingdom: Hodder Arnold; 2008: 335-351. Campbell JN, Meyer RA. Mechanisms of neuropathic pain. Neuron. 2006 Oct 5;52(1):77-92.


Postherpetic Neuralgia: Definition Postherpetic Neuralgia (PHN) results from herpes zoster (HZ) –Pain persisting at least 120 days after rash Herpes zoster is caused by varicella-zoster virus (VZV) –VZV causes: chickenpox and herpes zoster Herpes zoster represents reactivation of VZV in later life Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005 Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19.


Postherpetic Neuralgia: Epidemiology  20% lifetime risk of developing herpes zoster; 50% risk at age 85  PHN, the most common complication of HZ defined as at least 120 days of documented pain – <60 years of age (5%) – 60 to 69 years of age (10%) – 70 to 79 years of age (17%) – ≥ 80 years of age (20%)  9-34% of HZ patients develop PHN Yawn BP et al. Mayo Clin Proc. 2007;82:1341–1349. Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005


Postherpetic Neuralgia: Risk Factors  Older age (strongest predictor)  Greater acute pain intensity with HZ  Greater severity of the HZ rash  Presence and greater severity of a painful prodrome preceding the rash  Psychosocial distress  Immunocompromised state Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19. Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005


Postherpetic Neuralgia: Clinical Features  HZ: vesicular rash, unilateral, dermatomal –Thoracic region and ophthalmic branch of trigeminal nerve –Prodromal sx (before lesions develop): sharp, stabbing pain, pruritus, paresthesias –Lesion pain: burning/shooting –Post lesion pain (PHN): allodynia, hyperalgesia, tingling, pruritus, burning, throbbing, shooting Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19. Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005


Postherpetic Neuralgia: Clinical Features Constitutional Symptoms in Older Adults –chronic fatigue, anorexia, weight loss, inactivity, insomnia, depression

Can interfere with dressing, bathing, grooming, eating, mobility Allodynia can curtail traveling, shopping, cooking, housework Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005


PHN: Prevention (Vaccines) Live, attenuated varicella virus vaccine against varicella zoster virus (VZV) given to children –VZV: community acquired infection causing chickenpox –May decrease incidence of chickenpox and therefore, PHN

Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19.


PHN: Prevention (Vaccines) (cont’d) Live, attenuated zoster vaccine against HZ –≥60 yrs –Associated with >50% ↓ in incidence of HZ illness, 66% ↓ in PHN incidence, 61% ↓ in illness burden

Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005; 352 (22): 2271-84


PHN: Prevention (Antivirals) Prompt treatment of HZ with antiviral can reduce symptoms of acute pain and may decrease progression to PHN –Acyclovir, Valacyclovir, Famciclovir • All effectively treat HZ pain, safe, well tolerated

–Initiate within 72 hrs of lesion onset ideally

Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19.


PHN: Treatment (Pharmacological)  The US Food and Drug Administration has approved 5 medications for the treatment of PHN  Gabapentin & extended-release gabapentin (q 24°)  Lidocaine patch 5%  Pregabalin  Topical capsaicin 8% patch  Other effective medications – Tricyclic Antidepressants: nortriptyline, desipramine (screening EKG R/O conduction abnormalities recommended in older adults) Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19. Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005 Wallace MS, Irving G, Cowles VE Gabapentin extended-release tablets for the treatment of patients with postherpetic neuralgia: a randomized, double-blind, placebo-controlled, multicentre study. Clinical Drug Investigation 2010;30(11):765-76 Irving G, Jensen M, Cramer M, Wu J, Chiang YK, Tark M, Wallace M Efficacy and tolerability of gastric-retentive gabapentin for the treatment of postherpetic neuralgia: results of a double-blind, randomized, placebo-controlled clinical trial. The Clinical Journal of Pain 2009 Mar-Apr;25(3):185-92


PHN: Treatment (Pharmacological) (cont’d) Opioids: Mounting evidence supporting value in PHN –Consider sustained-release morphine, controlled-release oxycodone • Studied in PHN specifically

–Consider transdermal fentanyl, oxymorphone, methadone if others ineffective or adverse effects

Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19. Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005 AGS Panel on Persistent Pain in Older Persons. Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc (57) 8:2009, 1331-1346


PHN: Treatment (Pharmacological) (cont’d) Tramadol: studies show effectiveness in PHN Topical Lidocaine: –5% Lidocaine patch approved for PHN •Reduces pain and allodynia; mechanical barrier as well

–5% Lidocaine gel and 2.5% lidocaine/2.5% prilocaine •Reduces pain and allodynia in PHN studies Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19.


PHN: Treatment (Pharmacological) (cont’d) Capsaicin: effective in reducing pain in PHN –Extract of hot chili peppers –Apply cream or lotion (0.025% or 0.075%) 3-5 times daily –Discomfort and burning on application

Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19.


PHN: Treatment (Procedures) Intrathecal Corticosteroids –Intrathecal (IT) methylprednisolone (preservative free) effective in reducing PHN pain • 6 months-2 years of relief

–Risk of neurological sequelae in case series for non-PHN conditions –Preservative free methylprednisolone not available in US and not approved for IT use Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19.


PHN: Treatment (Procedures) (cont’d) Spinal Cord Stimulation –Retrospective and prospective case series document pain relief over 2-3 year period –For thoracic symptoms –Unrelenting pain in PHN patients –Alternative for those failing other therapies –? Peripheral stimulation for ophthalmic symptoms Christo PJ, Hobelmann G, Maine D: Post Herpetic Neuralgia in Older Adults: Evidence-Based Approaches to Clinical Management. Drugs and Aging 2007: 24 (1):1-19.


Postoperative Pain in Elders: Epidemiology  One third of inpatient surgeries performed on those 65 years and older – Proportion is increasing – Common surgeries: eye, orthopedic, thoracic, cardiac, vascular, gastrointestinal, urologic, cancer procedures

 Postoperative pain often undertreated in older patients, despite improvements in surgical techniques, pain control methods, education Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005


Postoperative Pain in Elders: Problems Receive less analgesia, given less pain medication than younger patients Given IM route and used prn despite evidence that these are ineffective –IM: Muscle wasting and less fatty tissue = unreliable absorption –prn: elders reluctant to ask, lag time long, doses inadequate Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005


Postoperative Pain in Elders: Impact Unrelieved postoperative pain in elders: –Confusion, delirium –Immobility : missed PT, less ambulation –Pulmonary complications: sig. morbidity and mortality in older patients –Long term effects: prolonged convalescence, functional disability, chronic pain, ↑ mortality

Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005


Postoperative Pain in Elders: Treatments Multimodal Analgesia –Recommended approach in older adults –Combines analgesics to allow lower doses of each one, fewer side effects, better pain control •Acetaminophen, NSAIDS, opioids, local anesthetics

Gibson SJ, Weiner DK, (eds.): Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005


Postoperative Analgesia in Elders: Treatments  NSAIDS/Acetaminophen: mild/moderate postop pain • Opioid sparing • AHCPR recommends use unless contraindication

 Opioids: Cornerstone for moderate-severe postop pain – Decrease starting dose by 25-50% & titrate slowly, but interindividual differences

Gibson SJ, Weiner DK, (eds .):Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005


Postoperative Analgesia in Elders: Treatments Treat opioid-induced side effects: –Constipation: laxatives –N/V: intraoperative antiemetics –Ileus: early oral feeding & aggressive ambulation –Mental Status Changes: pain as contributor > analgesics; IV PCA and epidural anesthesia assoc. with less sedation and mental dysfunction

Gibson SJ, Weiner DK, (eds .):Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005


Postoperative Analgesia in Elders: Treatments (cont’d) Patient-Controlled Analgesia –IV PCA safe and effective in older adults –Offer to those cognitively intact and physically able to press button –Don’t let family members activate PCA unless designated

Epidural Analgesia –Long history of safety & effectiveness in older patients (opioids + local anesthetics) Gibson SJ, Weiner DK, (eds .):Pain in Older Persons. Progress in Pain Research and Management, IASP Press, 2005


Summary Pain will increase in prevalence as the population ages Tolerance to pain decreases with age Be aware of specific painful conditions affecting older adults (OA, LBP, PHN, Postoperative pain) and tailor treatments according to recent guidelines and best evidence. Management of chronic pain syndromes is a multi-modal approach AGS Panel on Persistent Pain in Older Persons. Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc (57) 8:2009


Common Pain Syndromes Older Adults