Una E. Makris

Management of Persistent Pain in the Older Patient A Clinical Review

IMPORTANCE Persistent pain is highly prevalent, costly, and frequently disabling in later life. OBJECTIVE To describe barriers to the management of persistent pain among older adults, summarize current management approaches, including pharmacologic and nonpharmacologic modalities; present rehabilitative approaches; and highlight aspects of the patient-physician relationship that can help to improve treatment outcomes. This review is relevant for physicians who seek an age-appropriate approach to delivering pain care for the older adult. EVIDENCE ACQUISITION Search of MEDLINE and the Cochrane database from January 1990 through May 2014, using the search terms older adults, senior, ages 65 and above, elderly, and aged along with non-cancer pain, chronic pain, persistent pain, pain management, intractable pain, and refractory pain to identify English-language peer-reviewed systematic reviews, meta-analyses, Cochrane reviews, consensus statements, and guidelines relevant to the management of persistent pain in older adults. FINDINGS Of the 92 identified studies, 35 evaluated pharmacologic interventions, whereas 57 examined nonpharmacologic modalities; the majority (n = 50) focused on older adults with osteoarthritis. This evidence base supports a stepwise approach with acetaminophen as first-line therapy. If treatment goals are not met, a trial of a topical nonsteroidal anti-inflammatory drug, tramadol, or both is recommended. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. Careful surveillance to monitor for toxicity and efficacy is critical, given that advancing age increases risk for adverse effects. A multimodal approach is strongly recommended-emphasizing a combination of both pharmacologic and nonpharmacologic treatments to include physical and occupational rehabilitation, as well as cognitive-behavioral and movement-based interventions. An integrated pain management approach is ideally achieved by cultivating a strong therapeutic alliance between the older patient and the physician. CONCLUSIONS AND RELEVANCE Treatment planning for persistent pain in later life requires a clear understanding of the patients treatment goals and expectations, comorbidities, and cognitive and functional status, as well as coordinating community resources and family support when available. A combination of pharmacologic, nonpharmacologic, and rehabilitative approaches in addition to a strong therapeutic alliance between the patient and physician is essential in setting, adjusting, and achieving realistic goals of therapy.

Adverse effects of topical nonsteroidal antiinflammatory drugs in older adults with osteoarthritis: A systematic literature review

Objective. To systematically review the literature on reported adverse effects (AE) associated with use of topical nonsteroidal antiinflammatory drugs (NSAID) in older adults with osteoarthritis (OA). Methods. A systematic search of Medline (1950 to November 2009), Scopus, Embase, Web of Science, Cochrane databases, Dissertation and American College of Rheumatology meeting abstracts was performed to identify original randomized controlled trials, case reports, observational studies, editorials, or dissertations reporting AE from topical NSAID in older adults with OA. Information was sought on study and participant characteristics, detailed recording of application site, and systemic AE as well as withdrawals due to AE. Results. The initial search yielded 953 articles of which 19 met eligibility criteria. Subjects receiving topical NSAID reported up to 39.3% application site AE, and up to 17.5% systemic AE. Five cases of warfarin potentiation with topical agents were reported, 1 resulting in gastrointestinal bleeding. In formal trials, the withdrawal rate from AE ranged from 0 to 21% in the topical agents, 0 to 25% in the oral NSAID, and 0 to 16% in the placebo group. Conclusion. Although topical NSAID are safer than oral NSAID (fewer severe gastrointestinal AE), a substantial proportion of older adults report systemic AE with topical agents. The withdrawal rate due to AE with topical agents is comparable to that of oral NSAID. Given the safety profile and withdrawal rates described in this study, further data are needed to determine the incremental benefits of topical NSAID compared to other treatment modalities in older adults with OA.

Epidemiology of restricting back pain in community-living older persons.

OBJECTIVES: To estimate the incidence of back pain leading to restricted activity (restricting back pain) in community‐living older persons and to characterize its descriptive epidemiology.

Restricting back pain and subsequent mobility disability in community-living older persons.

To evaluate the relationship between back pain severe enough to restrict activity (restricting back pain) and subsequent mobility disability in community‐living older persons.

Risk Factors for Restricting Back Pain in Older Persons

OBJECTIVES To identify risk factors for back pain leading to restricted activity (restricting back pain) in older persons. DESIGN Prospective cohort study. SETTING Greater New Haven, Connecticut. PARTICIPANTS A total of 731 men and women aged 70 years or older, who were community living and nondisabled in essential activities of daily living at baseline. MEASUREMENTS Candidate risk factors were ascertained every 18 months for 108 months during comprehensive home-based assessments. Restricting back pain was assessed during monthly telephone interviews for up to 126 months. Incident episodes of (1) short-term (1 episode lasting 1 month) restricting back pain; and (2) persistent (1 episode lasting 2 or more months) or recurrent (2 or more episodes of any duration) restricting back pain were determined during each 18-month interval. The associations between the candidate risk factors and short-term and persistent/recurrent restricting back pain, respectively, were evaluated using a multivariable Cox model. RESULTS The cumulative incidence was 21.3% (95% confidence interval [CI] 19.6%-23.1%) for short-term restricting back pain and 20.6% (CI 18.6%-22.9%) for persistent/recurrent restricting back pain over a median follow-up of 109 months. In a recurrent event multivariable analysis, female sex (hazard ratio [HR] 1.30; 1.07-1.58), weak grip strength (HR 1.24; 1.01-1.52), and hip weakness (HR 1.19; 1.07-1.32) were independently associated with an increased likelihood of having short-term restricting back pain, whereas female sex (HR 1.48; CI 1.13-1.94), depressive symptoms (HR 1.57; 1.23-2.00), 2 or more chronic conditions (HR 1.38; 1.08-1.77), and arthritis (HR 1.66; 1.31-2.09) were independently associated with persistent/recurrent restricting back pain. CONCLUSION In this prospective study, several factors were independently associated with restricting back pain, including some that may be modifiable and therefore potential targets for interventions to reduce this common and often recurrent condition in older persons.

Augmented reality-based exergames for rehabilitation

Rehabilitation for stroke afflicted patients, through exercises tailored for individual needs, aims at relearning basic motor skills, especially in the extremities. Rehabilitation through Augmented Reality (AR) based games engage and motivate patients to perform exercises which, otherwise, maybe boring and monotonic. Also, mirror therapy allows users to observe ones own movements in the game providing them with good visual feedback. This paper presents an augmented reality based system for rehabilitation by playing four interactive, cognitive and fun Exergames (exercise and gaming). The system uses low-cost RGB-D cameras such as Microsoft Kinect V2 to capture and generate 3D model of the person by extracting him/her from the entire captured data and immersing it in different interactive virtual environments. Animation based limb movement enhancement along with cognitive aspects incorporated in the game can help in positive reinforcement, progressive challenges and motion improvement. Recording module of the toolkit allows future reference and facilitates feedback from the physician. 10 able-bodied users, 2 psychological experts and 2 Physical Medicine and Rehabilitation physicians evaluated the user experience and usability aspects of the exergames. Results obtained shows the games to be fun and realistic, and at the same time engaging and motivating for performing exercises.

Aging, the medical subspecialties, and career development: where we were, where we are going

Historically, the medical subspecialties have not focused on the needs of older adults. This has changed with the implementation of initiatives to integrate geriatrics and aging research into the medical and surgical subspecialties and with the establishment of a home for internal medicine specialists within the annual American Geriatrics Society (AGS) meeting. With the support of AGS, other professional societies, philanthropies, and federal agencies, efforts to integrate geriatrics into the medical and surgical subspecialties have focused largely on training the next generation of physicians and researchers. They have engaged several subspecialties, which have followed parallel paths in integrating geriatrics and aging research. As a result of these combined efforts, there has been enormous progress in the integration of geriatrics and aging research into the medical and surgical subspecialties, and topics once considered to be geriatric concerns are becoming mainstream in medicine, but this integration remains a work in progress and will need to adapt to changes associated with healthcare reform.

A Prospective Study of Back Pain and Risk of Falls Among Older Community-dwelling Women

BACKGROUND Back pain and falls are common health conditions among older U.S. women. The extent to which back pain is an independent risk factor for falls has not been established. METHODS We conducted a prospective study among 6,841 community-dwelling U.S. women at least 65 years of age from the Study of Osteoporotic Fractures (SOF). Baseline questionnaires inquired about any back pain, pain severity, and frequency in the past year. During 1 year of follow-up, falls were summed from self-reports obtained every 4 months. Two outcomes were studied: recurrent falls (≥2 falls) and any fall (≥1 fall). Associations of back pain and each fall outcome were estimated with risk ratios (RRs) and 95% confidence intervals (CIs) from multivariable log-binomial regression. Adjustments were made for age, education, smoking status, fainting history, hip pain, stroke history, vertebral fracture, and Geriatric Depression Scale. RESULTS Most (61%) women reported any back pain. During follow-up, 10% had recurrent falls and 26% fell at least once. Any back pain relative to no back pain was associated with a 50% increased risk of recurrent falls (multivariable RR = 1.5, 95% CI: 1.3, 1.8). Multivariable RRs for recurrent falls were significantly elevated for all back pain symptoms, ranging from 1.4 (95% CI: 1.1, 1.8) for mild back pain to 1.8 (95% CI: 1.4, 2.3) for activity-limiting back pain. RRs of any fall were also significantly increased albeit smaller than those for recurrent falls. CONCLUSIONS Older community-dwelling women with a recent history of back pain are at increased risk for falls.

Pharmacotherapies in Geriatric Chronic Pain Management

Pharmacologic management of chronic pain in older adults is one component of the multimodal, interdisciplinary management of this complex condition. In this article, we summarize several of the key barriers to effective pharmacologic management in older adults and review the existing (albeit limited) evidence for its effectiveness and safety, especially in a medically complex population with multimorbidity. This review covers topical formulations, acetaminophen, oral nonsteroidal antiinflammatory drugs, and adjuvant therapies. The article concludes with a suggested approach to managing chronic pain in the older patient, incorporating goals and expectations for treatment as well as careful monitoring of medication adjustments.

Physical, Emotional, and Social Impacts of Restricting Back Pain in Older Adults: A Qualitative Study.

Objective Back pain is the most common type of pain reported by older adults, yet current management strategies often do not address the multi-dimensional impacts on older adults who face unique challenges as compared with younger populations. The objective of this qualitative study was to assess the physical, psychological, and social impacts of back pain (severe enough to restrict activity, hereafter referred to as restricting back pain) on older adults. Design This was a qualitative study using semi-structured interviews and focus groups. Setting and Patients This study was comprised of a diverse sample of 93 community-living older adults (median age 83) with restricting back pain. Methods We used a semi-structured guide in 23 interviews and 16 focus groups to discuss the various ways that restricting back pain impacted participants. Transcripts were analyzed in an iterative process to develop thematic categories. Results Restricting back pain affected participants physically (inability to execute routine tasks, disruption of sleep and exercise), psychologically (feelings of sadness and irritability, fears about worsening health, loss of hope towards recovery or pain relief), and socially (experiences of isolation, inability to pursue hobbies). Conclusions These data inform which outcomes should be measured in studies evaluating treatments for older adults with restricting back pain.