Pain Management

  • Calvin H. HirschEmail author


Between 25% and 76% of older patients experience chronic pain, and 10–20% suffer from mood disorders. More severe chronic pain is associated with more severe depression or anxiety, and worse depression or anxiety predicts worse chronic pain. Chronic pain, insomnia, major depressive disorder, and advanced age itself all cause a state of neuroinflammation that involves increased production of inflammatory cytokines within the brain and results in overall greater sensitivity to painful stimuli and a consequent worsening of the chronic pain and linked mood disorder. The under-recognition and undertreatment of chronic pain in older adults admitted to the hospital mandate that a standardized pain assessment be integrated into the psychiatric admission history and physical examination. Pain in older adults with impaired communication due to a psychiatric condition or a major neurocognitive disorder easily can be overlooked without a careful history from an informant or careful monitoring for behavioral signs of distress.

The overlapping goals of chronic pain management include palliation, treatment of the underlying cause, optimizing physical functioning, and optimizing psychosocial functioning. The emphasis given to each treatment goal will vary according to the cause, severity, and impact of the individual patient’s pain. A stepwise pharmacological approach to pain remains the mainstay for inpatient management and emphasizes starting with safer analgesics first and advancing to the lowest effective dose of opioid that will achieve the goals for pain management developed for the patient. In moderate to severe pain, adjunctive analgesics like the selective norepinephrine reuptake inhibitors (SNRIs) and the gabapentinoids can be added to minimize opioid requirements; these agents are considered first-line therapy for neuropathic pain. Age-associated changes in pharmacokinetics and pharmacodynamics, the risk of adverse drug reactions, and drug interactions due to polypharmacy require that analgesics be introduced at a low dose and increased gradually, monitoring for side effects. As a class, non-steroidal anti-inflammatory drugs (NSAIDs) generally should be avoided because of the high risk of gastrointestinal and cardiovascular side effects in older patients. For suitable, long-term psychiatric in-patients with mild to moderate chronic pain, behavioral therapies can be tried as an alternative or supplemental intervention, although the evidence for their efficacy is limited.


Analgesics  Chronic pain  Cognitive impairment  Depression Inpatient psychiatry  Neuroinflammation Pain management 


  1. 1.
    Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, et al. Guidance on the management of pain in older people. Age Ageing. 2013;42(Suppl 1):i1–57.CrossRefGoogle Scholar
  2. 2.
    Larsson C, Hansson EE, Sundquist K, Jakobsson U. Chronic pain in older adults: prevalence, incidence, and risk factors. Scand J Rheumatol. 2017;46(4):317–25.CrossRefGoogle Scholar
  3. 3.
    Ismail Z, Arenovich T, Grieve C, Willett P, Sajeev G, Mamo DC, et al. Predicting hospital length of stay for geriatric patients with mood disorders. Can J Psychiatr. 2012;57(11):696–703.CrossRefGoogle Scholar
  4. 4.
    Scholz J, Woolf CJ. The neuropathic pain triad: neurons, immune cells and glia. Nat Neurosci. 2007;10(11):1361–8.CrossRefGoogle Scholar
  5. 5.
    McDougall FA, Kvaal K, Matthews FE, Paykel E, Jones PB, Dewey ME, et al. Prevalence of depression in older people in England and Wales: the MRC CFA study. Psychol Med. 2007;37(12):1787–95.CrossRefGoogle Scholar
  6. 6.
    Schulz R, Beach SR, Ives DG, Martire LM, Ariyo AA, Kop WJ. Association between depression and mortality in older adults: the cardiovascular health study. Arch Intern Med. 2000;160(12):1761–8.CrossRefGoogle Scholar
  7. 7.
    Weyerer S, Eifflaender-Gorfer S, Kohler L, Jessen F, Maier W, Fuchs A, et al. Prevalence and risk factors for depression in non-demented primary care attenders aged 75 years and older. J Affect Disord. 2008;111(2-3):153–63.CrossRefGoogle Scholar
  8. 8.
    Zis P, Daskalaki A, Bountouni I, Sykioti P, Varrassi G, Paladini A. Depression and chronic pain in the elderly: links and management challenges. Clin Interv Aging. 2017;12:709–20.CrossRefGoogle Scholar
  9. 9.
    de Heer EW, Gerrits MM, Beekman AT, Dekker J, van Marwijk HW, de Waal MW, et al. The association of depression and anxiety with pain: a study from NESDA. PLoS One. 2014;9(10):e106907.CrossRefGoogle Scholar
  10. 10.
    Blumer D, Heilbronn M. Chronic pain as a variant of depressive disease: the pain-prone disorder. J Nerv Ment Dis. 1982;170(7):381–406.CrossRefGoogle Scholar
  11. 11.
    Paladini A, Fusco M, Coaccioli S, Skaper SD, Varrassi G. Chronic pain in the elderly: the case for new therapeutic strategies. Pain Physician. 2015;18(5):E863–76.PubMedGoogle Scholar
  12. 12.
    Curatolo M, Muller M, Ashraf A, Neziri AY, Streitberger K, Andersen OK, et al. Pain hypersensitivity and spinal nociceptive hypersensitivity in chronic pain: prevalence and associated factors. Pain. 2015;156(11):2373–82.CrossRefGoogle Scholar
  13. 13.
    Boakye PA, Olechowski C, Rashiq S, Verrier MJ, Kerr B, Witmans M, et al. A critical review of neurobiological factors involved in the interactions between chronic pain, depression, and sleep disruption. Clin J Pain. 2016;32(4):327–36.CrossRefGoogle Scholar
  14. 14.
    Han C, Pae CU. Pain and depression: a neurobiological perspective of their relationship. Psychiatry Investig. 2015;12(1):1–8.CrossRefGoogle Scholar
  15. 15.
    Velly AM, Mohit S. Epidemiology of pain and relation to psychiatric disorders. Prog Neuro-Psychopharmacol Biol Psychiatry. 2018; 87(Pt B):159–167.CrossRefGoogle Scholar
  16. 16.
    Scherer M, Hansen H, Gensichen J, Mergenthal K, Riedel-Heller S, Weyerer S, et al. Association between multimorbidity patterns and chronic pain in elderly primary care patients: a cross-sectional observational study. BMC Fam Pract. 2016;17:68.CrossRefGoogle Scholar
  17. 17.
    Gianni W, Madaio RA, Di Cioccio L, D’Amico F, Policicchio D, Postacchini D, et al. Prevalence of pain in elderly hospitalized patients. Arch Gerontol Geriatr. 2010;51(3):273–6.CrossRefGoogle Scholar
  18. 18.
    Kress HG, Ahlbeck K, Aldington D, Alon E, Coaccioli S, Coluzzi F, et al. Managing chronic pain in elderly patients requires a CHANGE of approach. Curr Med Res Opin. 2014;30(6):1153–64.CrossRefGoogle Scholar
  19. 19.
    Blozik E, Stuck AE, Niemann S, Ferrell BA, Harari D, von Renteln-Kruse W, et al. Geriatric pain measure short form: development and initial evaluation. J Am Geriatr Soc. 2007;55(12):2045–50.CrossRefGoogle Scholar
  20. 20.
    Wong-Baker FACES Foundation. Welcome to the Wong-Baker FACES Foundation, the Official Home of the Wong-Baker FACES® Pain Rating Scale: Wong-Baker FACES Foundation; 2017 [cited 2017 December 31, 2017]. Available from:
  21. 21.
    University of Iowa College of Nursing Csomay Center of Gerontological Excellence. Resources and tools for quality pain care: The University of Iowa; 2017 [cited 2017 December 31, 2017]. Available from:
  22. 22.
    Coventry LL, Bremner AP, Williams TA, Celenza A, Jacobs IG, Finn J. Characteristics and outcomes of MI patients with and without chest pain: a cohort study. Heart Lung Circ. 2015;24(8):796–805.CrossRefGoogle Scholar
  23. 23.
    Leuthauser A, McVane B. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(2):363–75.CrossRefGoogle Scholar
  24. 24.
    FEt P, Vukov LF. Utility of fever and leukocytosis in acute surgical abdomens in octogenarians and beyond. J Gerontol A Biol Sci Med Sci. 1999;54(2):M55–8.CrossRefGoogle Scholar
  25. 25.
    O’Neil CK, Hanlon JT, Marcum ZA. Adverse effects of analgesics commonly used by older adults with osteoarthritis: focus on non-opioid and opioid analgesics. Am J Geriatr Pharmacother. 2012;10(6):331–42.CrossRefGoogle Scholar
  26. 26.
    Smith HS. Opioid metabolism. Mayo Clin Proc. 2009;84(7):613–24.CrossRefGoogle Scholar
  27. 27.
    Scarpignato C, Lanas A, Blandizzi C, Lems WF, Hermann M, Hunt RH. Safe prescribing of non-steroidal anti-inflammatory drugs in patients with osteoarthritis--an expert consensus addressing benefits as well as gastrointestinal and cardiovascular risks. BMC Med. 2015;13:55.CrossRefGoogle Scholar
  28. 28.
    Towheed TE, Maxwell L, Judd MG, Catton M, Hochberg MC, Wells G. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev. 2006;(1):Cd004257.Google Scholar
  29. 29.
    Kean WF, Rainsford KD, Kean IR. Management of chronic musculoskeletal pain in the elderly: opinions on oral medication use. Inflammopharmacology. 2008;16(2):53–75.CrossRefGoogle Scholar
  30. 30.
    Das M, Jain R, Dhawan A, Kaur A. Assessment of abuse liability of tramadol among experienced drug users: double-blind crossover randomized controlled trial. J Opioid Manag. 2016;12(6):421–30.CrossRefGoogle Scholar
  31. 31.
    Shaheen PE, Walsh D, Lasheen W, Davis MP, Lagman RL. Opioid equianalgesic tables: are they all equally dangerous? J Pain Symptom Manag. 2009;38(3):409–17.CrossRefGoogle Scholar
  32. 32.
    Cahill CM, Taylor AM. Neuroinflammation-a co-occurring phenomenon linking chronic pain and opioid dependence. Curr Opin Behav Sci. 2017;13:171–7.CrossRefGoogle Scholar
  33. 33.
    Lertxundi U, Domingo-Echaburu S, Hernandez R, Peral J, Medrano J. Expert-based drug lists to measure anticholinergic burden: similar names, different results. Psychogeriatrics. 2013;13(1):17–24.CrossRefGoogle Scholar
  34. 34.
    Schonfeld L, King-Kallimanis BL, Duchene DM, Etheridge RL, Herrera JR, Barry KL, et al. Screening and brief intervention for substance misuse among older adults: the Florida BRITE project. Am J Public Health. 2010;100(1):108–14.CrossRefGoogle Scholar
  35. 35.
    Simoni-Wastila L, Yang HK. Psychoactive drug abuse in older adults. Am J Geriatr Pharmacother. 2006;4(4):380–94.CrossRefGoogle Scholar
  36. 36.
    Sproule B. Prescription monitoring programs in Canada: best practice and program review: prescription drug monitoring programs in Canada: best practice and program review; 2015 [Available from:
  37. 37.
    State of California Department of Justice. Controlled substance utilization review and evaluation system (CURES 2.0) 2016 [CURES data base]. Available from:

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.General Medicine, Geriatrics, and Public Health SciencesUniversity of California, Davis Medical CenterSacramentoUSA

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