AAPM 2009: Expert Outlines Complexities of Pain Care for Older Adults

Allison Gandey

February 05, 2009

February 5, 2009 (Honolulu, Hawaii) — Treating chronic pain in older adults is very different from managing younger patients, reports a leading pain expert. Presenting at the American Academy of Pain Medicine 25th Annual Meeting, Debra Weiner, MD, from the University of Pittsburgh School of Medicine, in Pennsylvania, told specialists here that while degenerative pathology is a normal part of aging, pain is not and should be treated.

However, the management of chronic pain in elderly patients can be a complex proposition, she says, complicated by progressing cognitive impairment and physical changes brought about by years spent in pain.

"Healthcare professionals who do try to treat pain [in the elderly] are often unsuccessful because they don't have the right tools," Dr. Weiner said. She led a plenary session here, outlining some of the issues in treating this age group and pointing out some of what is still not known.

Only about 1% of pain studies address care for the elderly, she said, despite the fact that the population of those age 65 years and older is expected to increase by 75% between 2010 and 2030.

Plenary session moderator Perry Fine, MD, from the University of Utah School of Medicine, in Salt Lake City, said, "I don't think we’re fully prepared for the demographic shift that is taking place, and if we are not careful, we will be ill-equipped to deal with what is coming." He added, "Pennsylvania has really emerged as a center for pain expertise."

"My goal is simple," Dr. Weiner said during her talk. "It's to get you to think outside of the box when it comes to older pain patients."

Pain Predictive of Mortality?

Dr. Weiner showed that self-rated health is often predictive of morbidity and mortality. She then outlined how frequent pain is associated with poor self-rated health. "Chronic pain may therefore predict mortality," she said.

In the case of chronic low back pain, a highly prevalent problem among older adults, Dr. Weiner showed that patients tend to have more comorbidities. They also often have a higher body-mass index, require more medication, have sleep disorders and limitations on physical function, and lower overall neuropsychosocial performance.

While magnetic resonance imaging may demonstrate central canal stenosis, Dr. Weiner says this tells clinicians very little other than the patient is old. "Degenerative pathology is normal," she emphasized. "The big question is to what extent are normal age-related brain changes caused by pain? And are these changes modifiable?" More research is needed on these issues, not just for older adults but for the general population of pain patients, she added.

For some, opioid therapy may be indicated, but they have been linked to problems in older patients such as interfering with balance, promoting falls and confusion, depression, and agitation, she noted.

But Dr. Weiner pointed out that all of these problems can also be caused by chronic pain, and she urged clinicians to carefully weigh the risks and benefits of treatment.

Pain in the Cognitively Impaired

Treating chronic pain in patients with dementia is another important challenge, Dr. Weiner said. "Older adults with dementia are not simply cognitively impaired versions of those who are cognitively intact," she emphasized. "It is illogical to prescribe therapies in exactly the same way." It is therefore important to tailor pain management to the individual, she said.

Pain patients may also have undiagnosed dementia. "People fool me all the time," Dr. Weiner added. "If they are smart and have good social skills, their pain complaints may undermine the dementia." Dr. Weiner said that it is important to use a dementia screening algorithm even in patients who may not initially appear to have cognitive impairment.

Finally, Dr. Weiner urgedspecialists to work as part of a multidisciplinary team. She encouraged doctors to work with geriatricians, primary-care doctors, mental-health professionals, and rehabilitation therapists.

"Dr. Weiner is a world expert on pain care in older adults and gave a wonderful presentation," Robert Edwards, PhD, from Brigham and Women's Hospital, in Boston, Massachusetts, told Medscape Neurology & Neurosurgery. "She highlighted the complexity of care, and I learned a lot."

Dr. Weiner reports she has no relevant financial relationships to disclose.

American Academy of Pain Medicine 25th Annual Meeting: Plenary session 110. Presented January 31, 2009.

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