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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #12


Learning Objectives

  • Review the epidemiology of back pain in older adults, including associated psychosocial factors.

  • Understand how back pain is classified and its clinical course.

  • Recognize the broad differential of back pain etiology in older adults.

  • Understand the value of history, physical examination, and observation when evaluating an older adult with back pain and the indications for imaging in this population.

  • Select management of back pain in older adults that combines pharmacologic and nonpharmacologic (including behavioral, activity-based) modalities.

Key Clinical Points

  1. Back pain is one of the most common pain complaints among older adults leading to considerable morbidity and cost.

  2. Diagnostic and therapeutic costs have increased; however, outcomes have not improved.

  3. Back pain must be assessed in the context of comorbid conditions (including mental health conditions and potentially other sites of pain) as multimorbidity impacts management.

  4. Psychosocial factors (such as depression and pain related fear avoidance and/or pain catastrophizing) play an important role in the experience of back pain and potentially mediate the relationship with subsequent outcomes (such as disability).

  5. Infection, malignancy, and compression fractures must be ruled out prior to characterizing nonspecific mechanical back pain.

  6. Imaging of the spine often demonstrates anatomic abnormalities in asymptomatic older adults and should only be ordered in presence of red flags.

  7. A combination of pharmacologic, nonpharmacologic, and rehabilitative approaches (including physical therapy, occupational therapy, and/or spinal manipulation) in addition to a strong therapeutic alliance between the patient and physician is essential in setting, adjusting, and achieving realistic goals of therapy.

  8. Multimodal management programs for back pain can be tailored to the older adult’s preferences and abilities.


Low back pain in older adults is a major public health problem with significant consequences. Prevalence estimates range from 6% to 84% depending on the population evaluated, the study design, and the definition of back pain used. One study conducted in Israel found that 44% of 70-year-olds and 58% of 77-year-olds reported back pain. In the Framingham Heart Study cohort (ages 68–100), 22% of participants reported back pain on most days. As the second most common reason for visiting a physician, annual costs related to low back pain exceeded $100 billion (in 2005 dollars) and are expected to rise with the aging population. Over the past decade, health care–related spending on low back pain diagnostic and “therapeutic” procedures has skyrocketed, yet patient outcomes (in all age groups) have not improved.

A recent study, analyzing the data of more than 13 years, shows that older adults are more likely to develop recurrent episodes of back pain if they are female, suffer from depressive symptoms, have two or more chronic conditions, or self-report arthritis. Back pain in older adults is associated with dependence in daily living activities, mobility impairment, and poor self-reported health. The association of back pain and physical function ...

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