Pain Management

Abstract

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.