Some estimates indicate that about half of older adults living independently experience chronic pain. Chronic pain is defined as pain that persists for more than three to six months or beyond the expected healing time. The good news is that effective treatments are 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 are linked to health issues that more commonly occur as we age, such as osteoarthritis, chronic back pain, myofascial pain, peripheral neuropathy, fibromyalgia, falls, and the need for surgery. However, pain itself is complex, and the way the nervous system processes it changes as we age. Research suggests that older adults may have a higher threshold for pain but are less able to tolerate pain when it occurs.
Mood and cognition, how we perceive and process the world, also plays a key role in pain. Conditions like anxiety, depression, and loneliness can make pain feel more intense. Treatments such as cognitive behavioral therapy for pain, along with social supports and services like home care, can significantly improve quality of life for older adults living with chronic pain. It’s important to note that many of these factors are “bi-directional,” meaning they influence each other. For example, pain can lead to social isolation, which in turn can worsen pain. This is why a comprehensive approach to addressing multiple factors is needed to manage chronic pain effectively.
What are some of the treatments that are available to for pain?
Because 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. This is why a thorough pain assessment is essential. Geriatricians use the “5Ms of Geriatrics” model, which considers multiple factors: “mobility,” “mind,” “mood,” “medications,” “multi-complexity” (the presence of multiple medical conditions), and “matters most,” (which focuses on the patient’s personal goals).
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, depending on the individual’s needs and circumstances.
What does physical therapy consist of?
Physical therapy is very commonly recommended for older adults with chronic pain to help improve mobility, gait, and muscle strength, particularly in the muscles that support our joints.
An under-recognized specialty in medicine is physiatry, also called physical medicine and rehabilitation. Physiatrists focus on diagnosing and treating conditions that affect movement and function, often after injury or illness, such as stroke or spinal cord injury. 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.
Can you describe in more detail some of the other available pain treatments you mentioned?
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. Acupuncture is another method many people find effective, though it is often not rarely covered by insurance.
There are neuromodulation techniques for pain. One of the most commonly used is the transcutaneous electrical nerve stimulation (TENS) device, which applies low-voltage electrical currents to the nerves to help block or reduce pain signals.
Of course, 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, kidneys, and heart. With frequent daily use, we can see things like gastrointestinal bleeding, 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 generally safe dose that will not cause harm to your liver. Lidocaine patches or other topical treatments can also be effective. There are also 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 social interaction may be all that one needs to hold chronic pain at bay.
For pain that requires additional medication therapy, 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 like sleepiness, confusion, and euphoria, lower risk of addiction, and less constipation compared to other opioids. Most importantly, buprenorphine is associated with significantly less respiratory depression and overdose risk compared to traditional opioids, making it a much safer option.
What types of surgery are offered for pain?
Surgery for back pain and knee or hip replacement surgeries have become more common, especially with advances in minimally invasive techniques. However, there are many non-surgical remedies that can be tried before going that route. In most cases, orthopedic surgeons or neurosurgeons will recommend starting with non-surgical options first.
The good news is that a wide range of treatments is available. I encourage people to start with their primary care doctor, who can guide them and refer them to appropriate specialists if needed.
