Some estimates suggest that approximately half of older adults living on their own experience chronic pain. Chronic pain is defined as pain that lasts more than three to six months or longer than the expected healing time. The good news is that there are treatments available.
Lauren A. Kelly, MD
“People often look for the magic pill,” says Lauren A. Kelly, MD, a geriatrician at The Mount Sinai Hospital. “But pain is complex. Taking a multifaceted approach to healing can help us achieve the most successful and enduring results.”
In this Q&A, Dr. Kelly, Assistant Professor, Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, discusses why older adults experience pain and how it can be treated.
What causes pain among older adults?
There are many causes. Some can be attributed to health issues that more commonly occur as we age, such as osteoarthritis, chronic back pain, myofascial pain, peripheral neuropathy, fibromyalgia syndrome, falls, and the need for surgery. But the way we experience pain is complex and the way the nervous system processes pain changes as we age. Some studies show that older adults have a higher threshold for pain but are less able to tolerate it when it occurs. Mood and cognition, or the way our minds process the world around us, play an important part. Anxiety, depression, and loneliness can make pain more intense. Cognitive behavioral therapy for pain, as well as social supports and services like home care can significantly improve quality of life for older adults living with pain. It’s important to note that many of these factors are what we call “bi-directional,” which means each factor can influence the other. For instance, pain can increase social isolation, which in turn can lead to increased pain. This is why a comprehensive approach to addressing multiple factors is needed.
What are some of the treatments that are available to treat pain?
Since pain is so multifaceted, pain treatment should also be many-sided. People often look for simple solutions to relieve pain, but it’s much more nuanced than that. That’s also why the pain assessment is so important. Geriatricians use a model of multiple considerations called the “5Ms of Geriatrics,” which include “mobility,” “mind,” “mood,” “medications,” “multi-complexity,” or the presence of multiple medical conditions, and “matters most,” which takes the patient’s goals into consideration.
Once the patient’s goals are identified, we can develop a meaningful pain management program. Some of the treatments that might be considered include physical therapy, medication, pain injections, surgery, and even behavioral therapy.
What does physical therapy consist of?
Physical therapy is very commonly recommended for older adults with chronic pain to help improve mobility and gait and to strengthen the muscles that support our joints.
An under-recognized specialty in medicine is physiatry, also called physical medicine and rehabilitation. Physiatrists often care for patients with complex conditions such as stroke or significant physical injuries and deformities. They are also highly skilled in diagnosing and managing various types of pain, particularly musculoskeletal pain, and collaborate closely with physical and occupational therapists to enhance pain relief and functional recovery.
There are various approaches to treating nerve-related pain, such as neuromodulation techniques. One of the most common is the use of a transcutaneous electrical nerve stimulation (TENS) device, which applies low-voltage electrical currents to the nerves to help block or reduce pain signals. Acupuncture is another method many people find effective, though it is often not covered by insurance.
Pain specialists often utilize interventional procedures for pain, such as cortisone injections into the joints or painful trigger points, or epidural steroid injections into the spine. In some cases, they may perform nerve ablation to reduce pain, which can be highly effective for certain conditions. Additionally, medications remain an important tool in pain management.
What do older adults need to know about pain medications?
It’s important to know all the medications you are taking to avoid adverse reactions when new medications are added. Certain medications that are commonly used can have untoward effects for older adults. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, are a very powerful class of medication for inflammatory pain and osteoarthritis, but older adults need to be careful about overusing them due to negative effects on the gastrointestinal system, the kidneys, and the heart. With frequent daily use, we can see bleeding, ulcers in the GI tract, elevated blood pressure and kidney injury. It’s usually safe to use NSAIDs occasionally if you have never experienced these complications, but it’s best to talk with your doctor to understand what personalized recommendations they may have for you.
What medications might I be offered?
I think acetaminophen is undervalued and underutilized by patients. I usually advise my older adult patients with chronic pain who do not have significant liver impairment to take two extra strength 500 milligram acetaminophen tabs (1000mg total) up to two or three times a day. This is a safe dose that does not cause harm to your liver. Lidocaine patches or other topical treatments can also be effective. There are even topical NSAIDs available, which don’t get systemically absorbed when applied to the skin.
Low risk medications like acetaminophen and topical therapies, when combined with other treatments for pain, such as physical therapy, acupuncture, and a healthy routine that involves appropriate exercise, diet, and socialization may be all that one needs to hold chronic pain at bay.
For pain that requires more medication, there are several different classes of medications we reach for depending on the pain source. There is a class of drugs used for nerve-related pain, called neuropathic medications. These are medications like gabapentin and pregabalin. Some antidepressant medications have nerve pain effects, including the selective serotonin reuptake inhibitor (SNRI) class and tricyclic antidepressant (TCA) class, so we occasionally will use these medications for pain.
Opioids are sometimes prescribed after surgery or when other treatments have proven ineffective. Among this class of medications, I recommend buprenorphine. It has fewer side effects, including reduced cognitive effects, less sedation, and less constipation compared to other opioids. Most importantly, buprenorphine is associated with less respiratory depression compared to other opioids, making the likelihood of overdose much lower compared to traditional opioids..
What types of surgery are offered for pain?
Surgery for back pain and knee or hip replacement surgeries are becoming more common, especially with the increase in minimally invasive techniques. However, there are many remedies that can be tried before going that route. Even if you see an orthopedic surgeon or neurosurgeon, they will most often try non-surgical treatments first.
The good news is that there are a lot of treatments available. I encourage people to start with their primary care doctor who can refer you to the appropriate specialists as needed.