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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #10, #12, #13, #27, #56

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LEARNING OBJECTIVES

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Learning Objectives

  • Classify different types of pain.

  • Describe key pathophysiologic findings in chronic pain.

  • Review key aspects of pain evaluation and management.

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Key Clinical Points

  1. Older persons are more likely to underreport pain; underlying illnesses and cognitive impairment may make evaluation and treatment more difficult.

  2. Careful evaluation of pain requires a thorough history and physical supplemented by validated pain scales.

  3. Aggressive pharmacologic pain management, including the use of opioids, is appropriate in older adults but must require careful monitoring and attention to underlying comorbid conditions.

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OVERVIEW

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Pain is one of the most common symptoms for which patients seek medical attention. Approximately 116 million Americans are afflicted by chronic pain. Epidemiologic studies suggest three in five persons over age 65 report pain that lasted a year or more, and more than 15% report daily pain. In general, the most common causes of pain in older persons are probably related to musculoskeletal disorders such as back pain and arthritis. Neuralgia is also common, stemming from diseases such as diabetes, herpes zoster, and trauma such as surgery, amputation, and other nerve injuries. Nighttime leg pain (eg, cramps and restless legs) is also common, as is claudication. Cancer and its treatment, although not as common as arthritis, is often a source of severe pain. For patients near the end of life, the distress of cancer-related pain has resulted in an obligation for clinicians to provide effective comfort and palliative pain management. Management of persistent pain is associated with a number of negative outcomes in older adults. Depression, decreased socialization, sleep disturbance, falls, adverse drug events, and slow rehabilitation have all been associated with either the presence of pain or its treatment in older people. Older patients rely heavily on family and other caregivers near the end of life. For these patients and their caregivers, pain can be especially distressing. Caregiver strain and caregiver attitudes can have substantial impact on pain. In the final analysis increased utilization of health services and societal costs of treatment most likely exceeds $560 billion per year.

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The approach to pain management is often different in older versus younger persons. Older persons may underreport pain. They often present with concurrent illnesses and multiple problems, making pain evaluation and treatment more difficult. Dementia, delirium, a higher incidence of side effects to medications and higher potential for complications and adverse events related to many treatment procedures make pain assessment and management more difficult. Despite these challenges, pain can be effectively managed in most older patients. Moreover, clinicians have an ethical and moral obligation to prevent needless suffering and provide effective pain relief, especially for those near the end of life.

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HOW AGING AFFECTS PAIN PERCEPTION

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The effect of aging on pain ...

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