Managing chronic pain in older adults

It is a common belief that chronic pain is an unavoidable consequence of getting older. Seventy per cent of older adults experience pain due to medical conditions associated with ageing such as stroke, surgical procedures, diabetes, osteoarthritis and cardiovascular disease. 

In older people, chronic pain management includes multidisciplinary approaches based on pharmacotherapy, physical and psychological rehabilitation, and interventional approaches. 

Pharmacological agents used to treat chronic pain in older adults include NSAIDs, antidepressants, anticonvulsants, cannabinoids, muscle relaxants, naltrexone, memantine and opioids. To improve effectiveness and reduce the risk of side-effects, pharmacological approaches based on targeting multiple pain pathways are often used. Although this approach may allow for synergistic effects, it can contribute to polypharmacy and increased treatment burden, so must therefore be undertaken with caution.

Non-pharmaceutical pain management approaches include interventional therapies, rehabilitation and physical therapy, and psychological interventions. 

Interventional therapies such as lumbar facet injections, epidural steroid injections, sacroiliac joint injections, percutaneous vertebral augmentation, and hip and knee joint injections are generally low risk with few adverse effects. Benefits of interventional therapies include a reduced risk of side-effects and a reduced need for larger surgical interventions with higher risk and extended recovery time. 

Rehabilitation and physical therapy aim to reverse or improve loss of physiological or anatomical structure or function and to reduce the degree of patient disability due to impairment. 

Psychological interventions are primarily aimed at reducing co-morbid anxiety and depression and improving poor coping skills. These interventions also include approaches such as acceptance, commitment therapy and cognitive behavioural therapy. Psychological interventions for the treatment of chronic pain reduce pain and catastrophising beliefs and improve pain self-efficacy, particularly when delivered using group-based approaches. 

The role of pharmacists 

In chronic pain management, pharmacists are important members of the multidisciplinary team. They are in a position to review and adjust medication dosing, monitor polypharmacy and potential pharmacotherapy side-effects, deliver patient educational programmes, and advise on alternative routes of administration of analgesics based on individual needs.

Polypharmacy is prevalent in older adults, particularly those suffering from chronic pain. Pharmacists have an important role to play in ensuring adequate pain relief while at the same time avoiding medication overuse and reducing polypharmacy.

Pharmacists can also provide appropriate support for the administration of many treatment options such as topical analgesics, particularly for the management of localised and peripheral pain conditions. 

It is no surprise that older people are a target population to benefit from topical agents and clinical guidelines recommend their use for localised neuropathic and non-neuropathic pain. Additionally, community pharmacists may be more easily accessible to older patients than hospital-based services and able to act as communication hubs between patients and the wider chronic pain management team.