The American Geriatrics Society (AGS) has published the first clinical practice guidelines to focus specifically on the management of chronic pain in older persons. The guidelines were published in the May 1998 issue of the Journal of the American Geriatrics Society.
The recommendations in the report were derived from consensus among a panel of experts from the fields of geriatrics, pain management, psychology, pharmacology and nursing. The chair of the AGS Panel on Chronic Pain was Bruce Ferrell, M.D., University of California at Los Angeles School of Medicine. After an extensive search of the literature for articles on the subject of pain in older persons, panel members reviewed the reports and developed recommendations.
The guidelines are divided into four main sections: assessment of chronic pain in older persons, pharmacologic treatment of chronic pain, nonpharmacologic strategies for pain management in older persons and recommendations for health systems that care for older persons. In each section, general principles are presented with specific references provided, followed by the panel's recommendations for improving clinical assessment and management. The guidelines include a geriatric pain assessment document, a chronic pain record document, and tables that provide dosages, precautions and recommendations for various pain medications, including acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), opioid analgesic drugs and non-opioid drugs for analgesia.
According to the AGS, many of the 70 million Americans older than 50 years have chronic pain.One survey mentioned in the guidelines found that 45 percent of patients who take pain medications regularly had seen three or more physicians for pain in the past five years, and 79 percent of these physicians were primary care physicians. The diseases and conditions most likely to cause chronic pain in older persons include osteoarthritis, rheumatoid arthritis, other joint and bone disorders, back problems and neurologic disorders.
The guidelines recommend that physicians assess all of their older patients for evidence of chronic pain. Any persistent or recurrent pain should be considered significant. All patients with chronic pain should undergo a comprehensive pain assessment. It should include a thorough medical history and physical examination, as well as a review of the results of laboratory and other diagnostic tests. A quantitative assessment of pain should be made through the use of a standard pain scale. Patients and their caregivers should use a pain log or pain diary with regular entries for pain intensity, medication use, response to treatment and associated activities. Patients should be monitored regularly for improvement, deterioration or complications associated with treatment. The frequency of follow-up visits is determined by the severity of the pain syndrome and the potential for adverse effects from the treatment.
All pharmacologic agents used to treat pain have both benefits and adverse effects. The most common treatment to manage pain is the use of analgesic medications. The AGS panel recommends acetaminophen as first-line pharmacologic therapy for mild to moderate musculoskeletal pain. The maximum dosage of acetaminophen should not exceed 4,000 mg per day. The AGS advises extreme caution in the use of NSAIDs, such as aspirin and ibuprofen, because they are associated with a higher frequency of adverse effects in older adults. Short-acting NSAIDs may be preferable to avoid dose accumulation. NSAIDs should be avoided in patients with abnormal renal function, a history of peptic ulcer disease or a bleeding diathesis. Patients should not use more than one NSAID at a time.
The panel emphasizes that opioid analgesic drugs may be helpful for relieving moderate to severe pain, especially nociceptive pain. The use of opioid drugs for chronic non–cancer-related pain remains controversial, but the panel believes that opioids are probably underused in the treatment of older persons. The guidelines state that the fear of addiction and other side effects associated with opioid use does not justify failure to treat severe pain, especially in those persons near the end of life.
The doses of opioid analgesic medications needed for the treatment of non–cancer-related chronic pain are often lower than those used for cancer-related pain (see table).Monitoring is always necessary and should focus on neurologic and psychologic functions such as sedation, concentration and the ability to drive. Titration should be conducted carefully.
According to the panel, pharmacologic therapy is most effective when combined with nonpharmacologic strategies to optimize pain management. All patients with diminished quality of life associated with chronic pain are candidates for nonpharmacologic pain management strategies. Education should be provided to all patients with chronic pain and is considered by the panel to be a key factor in the management of pain. Nonpharmacologic interventions that can be used alone or in combination with pharmacologic strategies include cognitive-behavioral therapies, exercise, and trials of physical or occupational therapy. Other nonpharmacologic therapies include chiropractic treatment, acupuncture or transcutaneous electrical nerve stimulation; self-administered heat and cold; and massage and the use of liniments and other topical agents.
The panel urges regulatory agencies to change existing policies to improve access to narcotic, opioid analgesic drugs for older patients in pain and recommends health systems that care for older persons to allow for more aggressive treatment of chronic pain.
A brief summary of recommendations and considerations from the AGS guidelines follows:
Pain relief should become a priority. Providing treatment to relieve the pain is just as important as determining its cause.
A standard measure, such as a word list, visual or number pain scale, should be used to quantify both the severity of pain and its response to treatment.
NSAIDs should be used with caution, because they can have significant side effects to varying degrees in older patients.
Acetaminophen is the drug of choice for relieving mild to moderate musculoskeletal pain.
Opioid pain relievers are effective in relieving moderate to severe pain.
A variety of nonnarcotic analgesics have proved to be effective in the treatment of some pain associated with the nervous system and other chronic pain syndromes. Patients must be monitored closely.
If pain-relief goals are not being met, patients should be referred to multidisciplinary pain management centers.
Regulatory agencies should revise policies to make opioid pain relievers more readily available to older patients with pain.
Education about pain management should be improved for health care professionals at all levels of training and experience. Patients should also be educated about pain management.