Widespread Pain in Older Adults

  • Cheryl D. BernsteinEmail author
  • Jordan F. Karp
  • Debra K. Weiner


The differential diagnosis of widespread pain in older adults is broad, with fibromyaglia syndrome (FMS) leading the list. While the exact pathogenesis of FMS is not clear, recent studies suggest that abnormal pain processing and central sensitization contribute to the development of chronic muscle pain and tender points. Precise diagnosis of FMS requires a targeted history and physical examination. A multimodal treatment approach combining pharmacologic management, physical therapy, and cognitive behavioral techniques is effective for reducing pain and improving function and overall well-being. Antidepressant and anticonvulsant medications are widely used for FMS treatment. Depression and anxiety are common psychiatric comorbidities in older FMS patients that also require treatment to optimize outcomes.


Fibromyalgia syndrome Myofascial pain syndrome Tender points Trigger points Older adults Central sensitization Depression Anxiety Serotonin Norepinephrine Duloxetine Milnacipran Pregabalin Physical therapy Cognitive behavioral therapy 


  1. 1.
    Crook J, Rideout E, Brown G. The prevalence of pain complaints is a general population. Pain. 1984;18:299–314.PubMedCrossRefGoogle Scholar
  2. 2.
    Anderson S, Worm-Pederson J. The prevalence of persistent pain in a Danish population. In: Proceedings of the Fifth World Congress on Pain: Pain Supplement. Seattle, WA: International Association for the Study of Pain 1987;4:S332.Google Scholar
  3. 3.
    Magni G, Marchetti M, Moreschi C, et al. Chronic musculoskeletal pain and depressive symptoms in the National Health and Nutrition Examination. Epidemiologic follow-up study. Pain. 1993;53(2):163–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Sengstaken EA, King SA. The problems of pain and its detection among geriatric nursing home residents. J Am Geriatr Soc. 1993;41(5):541–4.PubMedGoogle Scholar
  5. 5.
    Schick FL, Schick R. Growth of the older population, actual and projected, 1900–2050. Table A1–9, Statistical handbook on aging Americans. Phoenix, Arizona: Oryx Press; 1994.Google Scholar
  6. 6.
    Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis and Rheum. 1990;33(2):160–72.CrossRefGoogle Scholar
  7. 7.
    Wolfe F, Ross K, Anderson J, et al. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum. 1995;38(1):19–28.PubMedCrossRefGoogle Scholar
  8. 8.
    Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum. 1998;41(5):778–99.PubMedCrossRefGoogle Scholar
  9. 9.
    Wolfe F. The clinical syndrome of fibrositis. Am J Med. 1986;81(Suppl 3A):7–14.PubMedCrossRefGoogle Scholar
  10. 10.
    Weir PT, Harlan GA, Nkoy FL. The incidence of fibromyalgia and its associated comorbidities. J Clin Rheumatol. 2006;12(3):124–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Yunus MB, Holt G, Masi AT, et al. Fibromyalgia syndrome among the elderly: Comparison with younger patients. J Am Geriatr Soc. 1998;36(11):987–95.Google Scholar
  12. 12.
    Cronan TA, Serber ER, Walen HR, et al. The influence of age on fibromyaglia symptoms. J Aging Health. 2002;14(3):370–84.PubMedCrossRefGoogle Scholar
  13. 13.
    Corran TM, Farrell MJ, Helme RD, et al. The classification of patients with chronic pain: age as a contributing factor. Clin Journal of Pain. 1997;13(3):207–14.CrossRefGoogle Scholar
  14. 14.
    Wright GE, Parker JC, Smarr KL, et al. Age, depressive symptoms, and rheumatoid arthritis. Arthritis Rheum. 1998;41(2):298–305.PubMedCrossRefGoogle Scholar
  15. 15.
    Baumstark KE, Buckelew SP, Sher KJ, et al. Pain behavior predictors among fibromyalgia patients. Pain. 1993;55(3):339–46.PubMedCrossRefGoogle Scholar
  16. 16.
    Yunus MB, Hold GS, Masi AT, et al. Fibromyalgia symptoms among the elderly: Comparison with younger patients. J Am Geriatr Soc. 1988;36:987–95.PubMedGoogle Scholar
  17. 17.
    Leveille SG, Ling S, Hochberg MC, et al. Widespread musculoskeletal pain and the progression of disability in older disabled women. Ann Intern Med. 2001;135(12):1038–46.PubMedGoogle Scholar
  18. 18.
    Leveille SG, Bean J, Bandeen-Roche K, et al. Musculoskeletal pain and risk for falls in older disabled women living in the community. J Am Geriatr Soc. 2002;50(4):671–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Leveille SG et al. Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA. 2009;302(20):2214–21.PubMedCrossRefGoogle Scholar
  20. 20.
    Geisser ME, Glass JM, Rajcevska LD, et al. A psychophysical study of auditory and pressure sensitivity with fibromyalgia and healthy controls. J Pain. 2008;9(5):417–22.PubMedCrossRefGoogle Scholar
  21. 21.
    Staud R, Rodriguez ME. Mechanisms of disease: pain in fibromyalgia syndrome. Nat Clin Pract Rheumatol. 2006;2(2):90–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Russel IJ, Orr MD, Littman B, et al. Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome. Arthritis Rheum. 1994;37(11):1593–601.CrossRefGoogle Scholar
  23. 23.
    Vaeroy H, Helle R, Forre O, et al. Elevated CSF levels of substance P and high incidence of Raynaud phenomenon in patients with fibromyalgia: new features for diagnosis. Pain. 1998;32(1):21–6.CrossRefGoogle Scholar
  24. 24.
    Welin M, Bragee B, Nyberg F, et al. Elevated substance P levels are contrasted by a decrease in met-enkephalin-arg-phe levels in CSF from fibromyalgia patients. J Musculoskelet Pain. 1995;3(suppl):4.Google Scholar
  25. 25.
    Bradley LA, Alberts KR, Alarcon GS, et al. Abnormal brain regional blood flow (fCBF) and cerebrospinal fluid (CSF) levels of substance P (SP) in patients and non-patients with fibromyalgia (FM). Arthritis Rheum. 1996;39 suppl 19:212.Google Scholar
  26. 26.
    Giovengo SL, Russell IJ, Larson AA. Increased concentrations of nerve growth factor in cerebrospinal fluid of patients with fibromyalgia. J Rheumatol. 1999;26(7):1564–9.PubMedGoogle Scholar
  27. 27.
    Russell IJ. Advances in fibromyalgia: possible role for central neurochemicals. Am J Med Sci. 1998;315(6):377–84.PubMedCrossRefGoogle Scholar
  28. 28.
    Murphy RM, Zelman FP. Differential effects of substance P on serotonin-modulated spinal nociceptive reflexes. Psychopharmacol (Berl). 1987;93(1):118–21.CrossRefGoogle Scholar
  29. 29.
    Schwarz MJ, Spath M, Muller-Bardoff H, et al. Relationship of substance P, 5-hydroxyindole acetic acid and tryptophan in serum of fibromyalgia patients. Neurosci Lett. 1999;259(3):196–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Crofford LJ, Pillemer SR, Kalogeras KT, et al. Hypothalamic-pituitary-adrenal axis perturbations in patients with fibromyalgia. Arthritis and Rheum. 1994;37(11):1583–92.CrossRefGoogle Scholar
  31. 31.
    McCain GA, Tilbe KS. Diurnal hormone variation in fibromyalgia syndrome: a comparison with rheumatoid arthritis. J Rheumatol Suppl. 1989;19:154–7.PubMedGoogle Scholar
  32. 32.
    Griep EN, Boersma JW, de Kloet ER. Altered reactivity of the hypothalamic-pituitary-adrenal axis in the primary fibromyalgia syndrome. J Rheumatol. 1993;20(3):469–74.PubMedGoogle Scholar
  33. 33.
    Tanriverdi F, Karaca Z, Unluhizarci K, et al. The hypothalamo-pituitary-adrenal axis in chronic fatigue and fibromyalgia syndrome. Stress. 2007;10(1):13–25.PubMedCrossRefGoogle Scholar
  34. 34.
    Zhuo M, Gebhart GF. Spinal cholinergic and monoaminergic receptors mediate descending inhibition from the nuclei reticularis gigantocellularis and gigantocellularis pars alpha in the rat. Brain Res. 1990;535(1):67–78.PubMedCrossRefGoogle Scholar
  35. 35.
    Zimmerman ME, Brickman AM, Paul RH, et al. The relationship between frontal gray matter volume and cognition varies across the healthy adult lifespan. Am J of Geriatr Psychiatry. 2006;14(10):823–33.CrossRefGoogle Scholar
  36. 36.
    Mitchell TW, Mufson EJ, Schneider JA, et al. Parahippocampal tau pathology in healthy aging, mild cognitive impairment, and early Alzheimer’s disease. Ann Neurol. 2002;51(2):182–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Cole LJ, Farrell MJ, Duff PE, et al. Pain sensitivity and fMRI pain-related brain activity in Alzheimer’s disease. Brain. 2006;129:2957–65.PubMedCrossRefGoogle Scholar
  38. 38.
    Benedetti F, Arduino C, Costa S, et al. Loss of expectation-related mechanisms in Alzheimers disease makes analgesic therapies less effective. Pain. 2006;121(1–2):133–44.PubMedCrossRefGoogle Scholar
  39. 39.
    Herr KA, Mobily PR. Comparison of selected pain assessment tools for use with the elderly. Appl Nurs Res. 1993;6(1):39–46.PubMedCrossRefGoogle Scholar
  40. 40.
    Karp JF, Weiner DK. Psychiatric care of the older adult with persistent pain. Eds: Maletta G, Argonon M. In: Principles and Practice of Geriatric Psychiatry, Chapter 42, New York: Lippincott Williams and Wilkins; 2006:657–76.Google Scholar
  41. 41.
    Weiner D, Peterson B, Keefe F. Evaluating persistent pain in long term care residents: What role for pain maps? Pain. 1998;76:249–57.PubMedCrossRefGoogle Scholar
  42. 42.
    Thieme K, Turk DC, Flor H. Comorbid depression and anxiety in fibromyalgia syndrome: relationship to somatic and psychosocial variables. Psychosom Med. 2004;66(6):837–44.PubMedCrossRefGoogle Scholar
  43. 43.
    MCBeth J, MacFarlane GJ, Benjamin S, et al. The association between tender points, psychological distress and adverse childhood experiences. Arthritis Rheum. 1999;42(7):1397–404.PubMedCrossRefGoogle Scholar
  44. 44.
    Arnold LM, Hudson JI, Hess EV, et al. Family study of fibromyalgia. Arthritis Rheum. 2004;50(3):944–52.PubMedCrossRefGoogle Scholar
  45. 45.
    Pope Jr HG, Hudson JI. A supplemental interview for forms of affective spectrum disorder. Int J Psychiatry Med. 1991;21(3):205–32.PubMedCrossRefGoogle Scholar
  46. 46.
    Borg-Stein J. Treatment of fibromyalgia, myofascial pain, and related disorders. Phys Med Rehab Clin of North America. 2006;17:491–510.Google Scholar
  47. 47.
    Rosenson RS. Current overview of statin-induced myopathy. Am J Med. 2004;116:408–16.PubMedCrossRefGoogle Scholar
  48. 48.
    Mulsant BH, Ganguli M. Epidemiology and diagnosis of depression late in life. J Clin Psychiatry. 1999;60:9–15.PubMedCrossRefGoogle Scholar
  49. 49.
    Cohen-Mansfield J, Marx MS. Pain and depression in the nursing home: corroborating results. J Gerontol. 1993;48(2):P96–7.PubMedGoogle Scholar
  50. 50.
    Jongenelis K, Pot AM, Eisses A, et al. Prevalence and risk indicators of depression in elderly nursing home patients: the AGED study. J Affect Disord. 2004;83(2–3):135–42.PubMedCrossRefGoogle Scholar
  51. 51.
    Lyness JM, Bruce ML, Koenig HG, et al. Depression and medical illness in late life: report of symposium. J Am Geriatr Soc. 1996;44(2):198–203.PubMedGoogle Scholar
  52. 52.
    Lyness JM, Caine ED, King DA, et al. Psychiatric disorders in older primary care patients. J Gen Intern Med. 1999;14(4):249–54.PubMedCrossRefGoogle Scholar
  53. 53.
    Lenze EJ, Mulsant BH, Shear MK, et al. Comorbid anxiety disorders in depressed elderly patients. Am J Psychiatry. 2000;157(5):722–8.PubMedCrossRefGoogle Scholar
  54. 54.
    Mulsant BH, Reynolds CF, Shear MK, et al. Comorbid anxiety ­disorders in late-life depression. Anxiety. 1996;2(5):242–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Parmelee P, Katz IR, Lawton MP. Anxiety and its association with depression among institutionalized elderly. Am J Geriatr Psychiatry. 1993;1:65–78.CrossRefGoogle Scholar
  56. 56.
    Wolfe F, Hawley DJ. Psychosocial factors and the fibromyalgia syndrome. Z Rheumatol. 1998;57 Suppl 2:88–91.PubMedCrossRefGoogle Scholar
  57. 57.
    White KP, Nielson WR, Harth M, et al. Chronic widespread musculoskeletal pain with or without fibromyalgia: psychological distress in a representative community adult sample. J Rheumatol. 2002;29(3):588–94.PubMedGoogle Scholar
  58. 58.
    Arnold LM, Lu Y, Crofford LJ, et al. A double blind, multicenter trial comparing duloxetine with placebo in the treatment of fibromyalgia patients with or without major depressive disorder. Arthritis Rheum. 2004;50(9):2974–84.PubMedCrossRefGoogle Scholar
  59. 59.
    Arnold LM, Rosen A, Pritchett YL, et al. A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with or without major depressive disorder. Pain. 2005;119(1–3):5–15.PubMedCrossRefGoogle Scholar
  60. 60.
    Arnold LM, Keck PE. Antidepressant treatment of fibromyalgia: a meta-analysis and review. Psychosomatics. 2000;41(2):104–13.PubMedCrossRefGoogle Scholar
  61. 61.
    Maizels M, McCarberg B. Antidepressant and antiepileptic drugs for the chronic non-cancer pain. Am Fam Physician. 2005;71(3):483–90.PubMedGoogle Scholar
  62. 62.
    O’Malley PG, Balden E, Tomkins G, et al. Treatment of fibromyalgia with antidepressants: a meta-analysis. J Gen Intern Med. 2000;15(9):659–66.PubMedCrossRefGoogle Scholar
  63. 63.
    Carette S, McCain GA, Bell DA, et al. Evaluation of amitriptyline in primary fibrositis. Arthritis Rheum. 1986;29(5):655–9.PubMedCrossRefGoogle Scholar
  64. 64.
    Goldenberg DL, Felson DT, Dinerman H. A randomized, controlled trial of amitriptyline and naproxen in the treatment of patients with fibromyalgia. Arthritis Rheum. 1986;29(11):1371–7.PubMedCrossRefGoogle Scholar
  65. 65.
    Santandrea S, Montrone F, Sarzi-Puttini P, et al. A double-blind crossover study of two cyclobenzaprine regimens in primary fibromyalgia syndrome. J Int Med Res. 1993;21(2):74–80.PubMedGoogle Scholar
  66. 66.
    Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med. 1997;157(14):1531–6.PubMedCrossRefGoogle Scholar
  67. 67.
    Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991;151(9):1825–32.PubMedCrossRefGoogle Scholar
  68. 68.
    Wolfe F, Cathey MA, Hawley DJ. A double-blind placebo controlled trial of fluoxetine in fibromyalgia. Scand J Rheumatol. 1994;23(5):255–9.PubMedCrossRefGoogle Scholar
  69. 69.
    Goldenberg D, Mayskiy M, Mossey C, et al. A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum. 1996;39(11):1852–9.PubMedCrossRefGoogle Scholar
  70. 70.
    Anderberg UM, Marteinsdottir I, von Knorring L. Citalopram in patients with fibromyalgia – a randomized, double-blind, placebo-controlled study. Eur J Pain. 2000;4(1):27–35.PubMedCrossRefGoogle Scholar
  71. 71.
    Karp J, Whyte E, Lenze E, et al. Rescue pharmacotherapy with duloxetine for selective serotonin reuptake inhibitor nonresponders in late-life depression: outcome and tolerability. J Clin Psychiatry. 2008;69(3):457–63.PubMedCrossRefGoogle Scholar
  72. 72.
    Raskin J, Wiltse CG, Dinkel JJ. Safety and tolerability of duloxetine at 60mg once daily in elderly patients with major depressive disorder. J Clin Psychopharmacol. 2008;28(1):32–8.PubMedCrossRefGoogle Scholar
  73. 73.
    Wohlreich MM, Mallinckrodt CH, Prakash A, et al. Duloxetine for the treatment of major depressive disorder in patients aged 65 and older: an open-label study. BMC Geriatr. 2004;7:4–11.Google Scholar
  74. 74.
    Russell IJ, Mease PJ, Smith TR, et al. Efficacy and safety of duloxetine for treatment of fibromyalgia in patients with or without major depressive disorder: Results from a 6-month, randomized, double-blind, placebo-controlled, fixed dose trial. Pain. 2008;136(3):432–44.PubMedCrossRefGoogle Scholar
  75. 75.
    Gendreau RM, Thorn MD, Gendreau JF, et al. Efficacy of milnacipran in patients with fibromyalgia. J Rheumatol. 2005;32(10):1975–85.PubMedGoogle Scholar
  76. 76.
    Mease PJ et al. The efficacy and safety of milnacipran for treatment of fibromyalgia. A randomized, double-blind, placebo-controlled trial. J Rheumatol. 2009;36(2):398–409.PubMedCrossRefGoogle Scholar
  77. 77.
    Dwight MM, Arnold LM, O’Brien H, et al. An open clinical trial of venlafaxine treatment of fibromyalgia. Psychosomatics. 1998;39(1):14–7.PubMedGoogle Scholar
  78. 78.
    Zijlstra TR, Barendregt P, van De Laar MA. Venlafaxine in fibromyalgia: results of a randomized placebo-controlled, double-blind trial. Eur J Pain. 2000;4(1):27–35.CrossRefGoogle Scholar
  79. 79.
    Crofford LJ, Mease PJ, Simpson SL, et al. Fibromyalgia relapse evaluation and efficacy for durability of meaningful relief (FREEDOM): a 6-month, double-blind, placebo-controlled trial with pregabalin. Pain. 2008;136(3):419–31.PubMedCrossRefGoogle Scholar
  80. 80.
    Arnold LM, Goldenberg DL, Stanford SB, et al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. 2007;56(4):1336–44.PubMedCrossRefGoogle Scholar
  81. 81.
    Harris RE, Clauw DJ, Scott DJ, et al. Decreased central mu-opioid receptor availability in fibromyalgia. J Neurosci. 2007;27:10000–6.PubMedCrossRefGoogle Scholar
  82. 82.
    Bennett RM, Kamin M, Karim R, et al. Tramadol and acetaminophen combination tablets in the treatment of fibromyalgia pain: a double-blind, placebo-controlled study. Am J Med. 2003;114(7):537–45.PubMedCrossRefGoogle Scholar
  83. 83.
    Dew MA, Hoch CC, Buysse DJ, et al. Healthy older adults’ sleep predicts all-cause mortality at 4 to 19 years of follow-up. Psychosom Med. 2003;65(1):63–73.PubMedCrossRefGoogle Scholar
  84. 84.
    Goldenberg DL, Burckhardt C, Crofford L. Management of ­fibromyalgia syndrome. JAMA. 2004;292(19):2388–95.PubMedCrossRefGoogle Scholar
  85. 85.
    Burckhart CS. Nonpharmacologic management strategies in fibromyalgia. Rheum Dis Clin North Am. 2002;28(2):291–304.CrossRefGoogle Scholar
  86. 86.
    Jones KD, Clark SR. Individualizing the exercise prescription for persons with fibromyalgia. Rheum Dis Clin North Am. 2002;28(2):419–36.PubMedCrossRefGoogle Scholar
  87. 87.
    Martin DP, Sletten CD, Williams BA, et al. Improvement in fibromyalgia symptoms with acupuncture: results of a randomized ­controlled trial. Mayo Clin Proc. 2006;81(6):749–57.PubMedCrossRefGoogle Scholar
  88. 88.
    Deluze C, Bosia L, Zirbs A. Electroacupunture in fibromyalgia: results of a controlled trial. BMJ. 1992;305(6864):1249–52.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Cheryl D. Bernstein
    • 1
    Email author
  • Jordan F. Karp
  • Debra K. Weiner
  1. 1.Department of AnesthesiologyUniversity of PittsburghPittsburghUSA

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