What are the best practices for managing chronic pain in older adults, considering their unique physiological changes?

Managing chronic pain in older adults requires a person-centred, holistic approach that accounts for their unique physiological changes such as altered pharmacokinetics, increased sensitivity to medications, and the presence of multiple comorbidities. A comprehensive assessment should identify contributing factors to pain and its impact on function and quality of life, involving shared decision-making with the patient and carers to establish priorities, goals, and preferred treatment approaches ¹,².

Non-pharmacological strategies are foundational and should include supervised group exercise programmes tailored to the older adult’s abilities and preferences, encouraging physical activity to maintain function and general health benefits ¹,². Psychological therapies such as cognitive behavioural therapy (CBT) or acceptance and commitment therapy (ACT) delivered by trained professionals can help address the emotional and behavioural aspects of chronic pain ¹,². Self-management support, including education on pain mechanisms, flare-up management, and use of pain diaries (preferably electronic), empowers older adults to actively participate in their care ¹,².

Pharmacological management must be cautious due to altered drug metabolism and increased risk of adverse effects in older adults. NICE guidelines advise against opioids for chronic primary pain due to lack of long-term benefit and potential harms, although SIGN guidelines suggest short- to medium-term opioid use may be considered in carefully selected cases where other treatments have failed, balancing risks such as addiction and overdose ¹. Gabapentinoids like pregabalin are generally not recommended for chronic primary pain but may be considered for specific conditions like fibromyalgia with careful monitoring ¹. Antidepressants such as duloxetine have moderate efficacy but require regular review to ensure benefits outweigh risks, especially considering polypharmacy and comorbid depression ¹.

Regular medication reviews are essential to assess ongoing need, effectiveness, and adverse effects, using a holistic polypharmacy approach to minimise harm ¹,². Transcutaneous electrical nerve stimulation (TENS) may be considered as an adjunct for pain relief, although evidence is limited and benefits vary ¹. Referral to pain specialists should be considered if pain is poorly controlled, distressing, or if specialist interventions are needed ¹.

Physiological changes in older adults, such as decreased renal and hepatic function, altered body composition, and increased sensitivity to central nervous system effects, necessitate careful dose adjustments and vigilant monitoring for side effects ¹[(Horgas, 2017)]. Environmental and psychosocial factors, including anxiety, depression, and social isolation, also influence pain experience and should be addressed as part of a multidisciplinary management plan ¹[(Horgas, 2017)].