Clinical Geriatrics

Introduction
We are all likely to experience pain at some point in our lives. How that pain is best managed depends on its etiology, acuity, and pathophysiology. Coexisting medical conditions and the potential risk for adverse effects play a larger role in treatment choices for older adults. In this article, we present treatment options for both acute and persistent pain. A step-wise approach with rationale for treatment choices is discussed. In addition to a variety of pharmacologic treatment options, physical therapeutics, modalities, and focused interventions are presented.

Treatment of Acute versus Persistent Pain
When considering management of pain in older adults, the choice of treatment depends on the acuity of the issue. Acute injuries or acute exacerbations of chronic conditions should be treated in a different way than persistent pain. Unless contraindicated, pharmacologic management of acute pain, including postoperative pain, should include 2-4 days of around-the-clock acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs can be administered in oral or topical form. If painful muscle spasms are present, a muscle relaxant should also be given. Initial doses should be administered at night in case sedation develops. If a patient is taking a chronic regimen of pain medications that includes a short-acting medication for breakthrough pain, the frequency should be increased, followed by an increase in dosage strength if required. The patient will need to be monitored for an increase in potential adverse events. Appropriate laboratory tests should be done to monitor kidney and liver function before any medication increase. If patients are taking long-term medications for pain management, including long-acting opiates, they should not be discontinued prior to any planned surgery. The surgeon and anesthesiologist should be informed of any medications being taken prior to the planned procedure. Coordination with the physician who is managing the patient’s pain should take place preoperatively to ensure that a plan is in place to allow the best postoperative pain control possible.

Nonpharmacologic methods should be included in any treatment plan for older adults with pain. Acute injuries will respond to the Rest, Ice, Compression, and Elevation, or RICE, principle; “R” stands for rest of the affected body part. Pain after an acute injury is a signal that there is tissue damage and is meant to serve a protective function. If it hurts to walk on a broken leg, you are less likely to walk on it and cause further damage. By not using an injured area, healing can occur. Immobilizing an injured area can help prevent motion through already damaged tissues. Examples of this include an elastic wrap applied to the injured area, a sling to prevent excessive shoulder motion, or an aircast for a sprained ankle. In addition, use of assistive devices such as canes or walkers can help decrease mechanical stress through an injured area. A single-point cane can unweight mechanical forces through the hip joint by up to 11%.¹ A walker provides even more support and is especially helpful if a lower extremity has weight-bearing restrictions due to an acute fracture. For patients who are non–weight-bearing, a standard walker, not a rolling walker, should be utilized to decrease the risk of falls. Walkers provide more stability than axillary crutches.