Treatment of Chronic and Persistent Pain in Older Persons

Functional limitations, which are typically a result of chronic health problems, are increasingly common with advancing age. For this reason, they’re often viewed as an inevitable part of aging. However, as Covinsky and colleagues¹ point out in a recent study in the Journal of the American Geriatrics Society (JAGS), there is significant variation in functional ability among older people. “Some are free of functional limitations even into their 90’s while others develop significant functional limitations well before ages that would be considered “old,”” they note in their study “Pain, Functional Limitations, and Aging.”

Given that pain is both common among those with functional disability and a risk factor for it, the researchers set out to investigate the extent to which pain contributes to the loss of function across a wide range of ages. The group studied more than 18,000 adults participating in the 2004 Health and Retirement Study, a nationally representative study of community-dwelling adults older than 50. The 24% of participants they classified as having “significant pain”—those who reported that they were often troubled by moderate or severe pain—were considerably more likely to have functional limitations, Covinsky and coauthors found after adjusting for comorbidities, demographic, and other relevant factors. These adults were nearly three times as likely to have mobility problems and to have difficulty climbing stairs; nearly four times as likely to have difficulty with upper extremity tasks, and more than four times as likely to have difficulty with daily activities as those who did not report such pain. In addition, adults with significant pain developed functional limitations 20-30 years earlier than those not experiencing significant pain.

In light of these findings, the researchers advise that patients with significant pain be evaluated for functional limitations, and those with such limitations be evaluated to determine whether they have significant pain. For those with pain and functional limitations, treatment should focus both on pain relief and therapy to improve functioning, the researchers conclude.

We agree. Many of the participants in the Covinsky study who were classified as having significant pain suffered from arthritis, one of the leading causes of chronic or persistent pain. To assist clinicians in treating such pain, the American Geriatrics Society recently updated its guideline for the pharmacolologic treatment of persistent pain. The previous guideline recommended that seniors use over-the-counter or prescription nonsteroidal anti-inflammatory drugs (NSAIDs) or COX-2 inhibitors before being prescribed an opioid drug. Published in the August JAGS, the updated guideline points to newer information suggesting that the risks of NSAIDs in older patients—which include increased cardiovascular risk and gastrointestinal toxicity—usually outweigh the benefits. Based on newer clinical trials as well as clinical observation, the new guideline recommends that NSAIDs and COX-2s be considered rarely, and with extreme caution, in highly selected individuals. The guideline recommends that all patients with moderate-severe pain or diminished quality of life due to pain be considered for opioid therapy, which may be safer for many patients than long-term use of NSAIDs. The guideline also provides recommendations and information about the use of adjuvant and other drugs for older persons with recalcitrant pain problems.

To help clinicians educate their patients and patients’ loved ones about the treatment of persistent pain, AGS’ Foundation for Health in Aging (FHA) has published an easy-to-read companion “tip sheet” about managing such pain that is based on the guideline. The tip sheet is now available in English on the FHA’s public education website (www.healthinaging.org) and will soon be available in Spanish. As with other tip sheets and information on the FHA website, these may be printed and shared at no cost.