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Treatment of persistent pain in older adults

Marissa C Galicia-Castillo, MD, MSEd, CMD, FACP
Debra K Weiner, MD, FACP
Section Editor
Kenneth E Schmader, MD
Deputy Editor
Marianna Crowley, MD


The population of older adults (age 65 and older) is growing, with numbers of the frailest, most pain-ridden, and oldest (persons 85 years and over) increasing the most rapidly. Up to 50 percent of community-dwelling older adults report pain that interferes with normal function, and at least half of nursing home residents report pain on a daily basis [1,2]. Medical, psychological, and social comorbidities, as well as environmental factors, may contribute to pain and/or impact treatment response [3].

This topic will discuss treatment of persistent (ie, chronic) non-cancer pain in the older adult, with an emphasis on the differences in management from younger adults. Other closely related, important issues related to treatment of pain in older adults are reviewed in detail separately:

(See "Evaluation of chronic pain in adults", section on 'Older adults'.)

(See "Overview of the treatment of chronic non-cancer pain".)

(See "Drug prescribing for older adults".)


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Literature review current through: Jun 2017. | This topic last updated: Jul 17, 2017.
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  1. Won AB, Lapane KL, Vallow S, et al. Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. J Am Geriatr Soc 2004; 52:867.
  2. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002; 50:S205.
  3. Reid MC, Eccleston C, Pillemer K. Management of chronic pain in older adults. BMJ 2015; 350:h532.
  4. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009; 57:1331.
  5. Scanlan J, Borson S. The Mini-Cog: receiver operating characteristics with expert and naïve raters. Int J Geriatr Psychiatry 2001; 16:216.
  6. Shega JW, Dale W, Andrew M, et al. Persistent pain and frailty: a case for homeostenosis. J Am Geriatr Soc 2012; 60:113.
  7. Weiner DK, Haggerty CL, Kritchevsky SB, et al. How does low back pain impact physical function in independent, well-functioning older adults? Evidence from the Health ABC Cohort and implications for the future. Pain Med 2003; 4:311.
  8. Leveille SG, Jones RN, Kiely DK, et al. Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA 2009; 302:2214.
  9. Bosley BN, Weiner DK, Rudy TE, Granieri E. Is chronic nonmalignant pain associated with decreased appetite in older adults? Preliminary evidence. J Am Geriatr Soc 2004; 52:247.
  10. Gentili A, Weiner DK, Kuchibhatil M, Edinger JD. Factors that disturb sleep in nursing home residents. Aging (Milano) 1997; 9:207.
  11. Wilson KG, Watson ST, Currie SR. Daily diary and ambulatory activity monitoring of sleep in patients with insomnia associated with chronic musculoskeletal pain. Pain 1998; 75:75.
  12. Casten RJ, Parmelee PA, Kleban MH, et al. The relationships among anxiety, depression, and pain in a geriatric institutionalized sample. Pain 1995; 61:271.
  13. Rudy TE, Weiner DK, Lieber SJ, et al. The impact of chronic low back pain on older adults: a comparative study of patients and controls. Pain 2007; 131:293.
  14. Husebo BS, Ballard C, Sandvik R, et al. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ 2011; 343:d4065.
  15. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003; 58:76.
  16. Weiner DK, Rudy TE, Morrow L, et al. The relationship between pain, neuropsychological performance, and physical function in community-dwelling older adults with chronic low back pain. Pain Med 2006; 7:60.
  17. Karp JF, Reynolds CF 3rd, Butters MA, et al. The relationship between pain and mental flexibility in older adult pain clinic patients. Pain Med 2006; 7:444.
  18. Baker KR, Nelson ME, Felson DT, et al. The efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial. J Rheumatol 2001; 28:1655.
  19. Weiner DK, Sakamoto S, Perera S, Breuer P. Chronic low back pain in older adults: prevalence, reliability, and validity of physical examination findings. J Am Geriatr Soc 2006; 54:11.
  20. Culberson JW, Ziska M. Prescription drug misuse/abuse in the elderly. Geriatrics 2008; 63:22.
  21. Weiner, D, Herr, K. Comprehensive Assessment and Interdisciplinary Treatment Planning: An Integrative Overview. In: Persistent Pain in Older Adults: An Interdisciplinary Guide for Treatment, Weiner, D, Herr, K, Rudy, T (Eds), Springer Publishing Company, 2002. p. 18.
  22. Weiner, D, Karp, J, Bernstein, C, Morone, N. Pain Medicine in Older Adults: How Should it Differ? In: Comprehensive Treatment of Chronic Pain by Medical, Interventional and Behavioral Approaches., Deer, T, Ray, A, Gordin, V, et al. (Eds), Springer, 2012. p. in press. AND Weiner, D, Herr, K. Comprehensive Assessment and Interdisciplinary Treatment Planning: An Integrative Overview. In:
  23. Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med 2008; 359:1108.
  24. Resnick NM, Marcantonio ER. How should clinical care of the aged differ? Lancet 1997; 350:1157.
  25. Bernstein, C, Weiner, D. Fibromyalgia and Myofascial Pain Syndromes. In: Hazzard's Principles of Geriatric Medicine and Gerontology, 6th Edition, 2009. p. 1491.
  26. Weiner DK, Schmader KE. Postherpetic pain: more than sensory neuralgia? Pain Med 2006; 7:243.
  27. Bernstein C, Weiner D. Fibromyalgia and Myofascial Pain Syndromes. In: Hazzard's Principles of Geriatric Medicine and Gerontology, 6th Edition, 2009. p. 1491.
  28. Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Clonazepam open clinical treatment trial for myofascial syndrome associated chronic pain. Pain Med 2000; 1:332.
  29. Hicks GE, Morone N, Weiner DK. Degenerative lumbar disc and facet disease in older adults: prevalence and clinical correlates. Spine (Phila Pa 1976) 2009; 34:1301.
  30. Jarvik JJ, Hollingworth W, Heagerty P, et al. The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data. Spine (Phila Pa 1976) 2001; 26:1158.
  31. Reid MC, Williams CS, Gill TM. Back pain and decline in lower extremity physical function among community-dwelling older persons. J Gerontol A Biol Sci Med Sci 2005; 60:793.
  32. Turner JA, Ersek M, Herron L, Deyo R. Surgery for lumbar spinal stenosis. Attempted meta-analysis of the literature. Spine (Phila Pa 1976) 1992; 17:1.
  33. Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine (Phila Pa 1976) 1996; 21:1787.
  34. Javid MJ, Hadar EJ. Long-term follow-up review of patients who underwent laminectomy for lumbar stenosis: a prospective study. J Neurosurg 1998; 89:1.
  35. Fokter SK, Yerby SA. Patient-based outcomes for the operative treatment of degenerative lumbar spinal stenosis. Eur Spine J 2006; 15:1661.
  36. Aalto TJ, Malmivaara A, Kovacs F, et al. Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review. Spine (Phila Pa 1976) 2006; 31:E648.
  37. Raffo CS, Lauerman WC. Predicting morbidity and mortality of lumbar spine arthrodesis in patients in their ninth decade. Spine (Phila Pa 1976) 2006; 31:99.
  38. Li G, Patil CG, Lad SP, et al. Effects of age and comorbidities on complication rates and adverse outcomes after lumbar laminectomy in elderly patients. Spine (Phila Pa 1976) 2008; 33:1250.
  39. Sinikallio S, Aalto T, Airaksinen O, et al. Depressive burden in the preoperative and early recovery phase predicts poorer surgery outcome among lumbar spinal stenosis patients: a one-year prospective follow-up study. Spine (Phila Pa 1976) 2009; 34:2573.
  40. Airaksinen O, Herno A, Turunen V, et al. Surgical outcome of 438 patients treated surgically for lumbar spinal stenosis. Spine (Phila Pa 1976) 1997; 22:2278.
  41. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008; 358:794.
  42. Weiner DK. Office management of chronic pain in the elderly. Am J Med 2007; 120:306.
  43. Weiner DK, Herr K. Comprehensive Assessment and Interdisciplinary Treatment Planning: An Integrative Overview. In: Persistent Pain in Older Adults: An Interdisciplinary Guide for Treatment, Weiner DK, Herr K, Rudy T (Eds), Springer Publishing Company, New York 2002. p.18.
  44. Park J, Hughes AK. Nonpharmacological approaches to the management of chronic pain in community-dwelling older adults: a review of empirical evidence. J Am Geriatr Soc 2012; 60:555.
  45. Ettinger WH Jr, Burns R, Messier SP, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA 1997; 277:25.
  46. Davis GC, White TL. A goal attainment pain management program for older adults with arthritis. Pain Manag Nurs 2008; 9:171.
  47. Reid MC, Papaleontiou M, Ong A, et al. Self-management strategies to reduce pain and improve function among older adults in community settings: a review of the evidence. Pain Med 2008; 9:409.
  48. Grant DJ, Bishop-Miller J, Winchester DM, et al. A randomized comparative trial of acupuncture versus transcutaneous electrical nerve stimulation for chronic back pain in the elderly. Pain 1999; 82:9.
  49. Ng MM, Leung MC, Poon DM. The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: a randomized controlled trial with follow-up evaluation. J Altern Complement Med 2003; 9:641.
  50. Weiner DK, Perera S, Rudy TE, et al. Efficacy of percutaneous electrical nerve stimulation and therapeutic exercise for older adults with chronic low back pain: a randomized controlled trial. Pain 2008; 140:344.
  51. Green SM, Hadjistavropoulos T, Hadjistavropoulos H, et al. A controlled investigation of a cognitive behavioural pain management program for older adults. Behav Cogn Psychother 2009; 37:221.
  52. Cramer H, Haller H, Lauche R, Dobos G. Mindfulness-based stress reduction for low back pain. A systematic review. BMC Complement Altern Med 2012; 12:162.
  53. Skingley A, Vella-Burrows T. Therapeutic effects of music and singing for older people. Nurs Stand 2010; 24:35.
  54. McCaffrey R, Freeman E. Effect of music on chronic osteoarthritis pain in older people. J Adv Nurs 2003; 44:517.
  55. Baird CL, Sands L. A pilot study of the effectiveness of guided imagery with progressive muscle relaxation to reduce chronic pain and mobility difficulties of osteoarthritis. Pain Manag Nurs 2004; 5:97.
  56. Baird CL, Murawski MM, Wu J. Efficacy of guided imagery with relaxation for osteoarthritis symptoms and medication intake. Pain Manag Nurs 2010; 11:56.
  57. Lewandowski WA. Patterning of pain and power with guided imagery. Nurs Sci Q 2004; 17:233.
  58. Barkin RL, Barkin SJ, Barkin DS. Pharmacotherapeutic management of pain with a focus directed at the geriatric patient. Rheum Dis Clin North Am 2007; 33:1.
  59. Kuehn BM. FDA focuses on drugs and liver damage: labeling and other changes for acetaminophen. JAMA 2009; 302:369.
  60. Gloth FM 3rd. Pharmacological management of persistent pain in older persons: focus on opioids and nonopioids. J Pain 2011; 12:S14.
  61. Scheiman JM, Hindley CE. Strategies to optimize treatment with NSAIDs in patients at risk for gastrointestinal and cardiovascular adverse events. Clin Ther 2010; 32:667.
  62. Bansal V, Dex T, Proskin H, Garreffa S. A look at the safety profile of over-the-counter naproxen sodium: a meta-analysis. J Clin Pharmacol 2001; 41:127.
  63. Lanza F, Rack MF, Doucette M, et al. An endoscopic comparison of the gastroduodenal injury seen with salsalate and naproxen. J Rheumatol 1989; 16:1570.
  64. Bianchi Porro G, Petrillo M, Ardizzone S. Salsalate in the treatment of rheumatoid arthritis: a double-blind clinical and gastroscopic trial versus piroxicam. II. Endoscopic evaluation. J Int Med Res 1989; 17:320.
  65. Jones P, Lamdin R. Oral cyclo-oxygenase 2 inhibitors versus other oral analgesics for acute soft tissue injury: systematic review and meta-analysis. Clin Drug Investig 2010; 30:419.
  66. Coxib and traditional NSAID Trialists' (CNT) Collaboration, Bhala N, Emberson J, et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet 2013; 382:769.
  67. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012; 60:616.
  68. Reisner L. Pharmacological management of persistent pain in older persons. J Pain 2011; 12:S21.
  69. Chew ML, Mulsant BH, Pollock BG, et al. Anticholinergic activity of 107 medications commonly used by older adults. J Am Geriatr Soc 2008; 56:1333.
  70. Coupland CA, Dhiman P, Barton G, et al. A study of the safety and harms of antidepressant drugs for older people: a cohort study using a large primary care database. Health Technol Assess 2011; 15:1.
  71. Moore RA, Straube S, Wiffen PJ, et al. Pregabalin for acute and chronic pain in adults. Cochrane Database Syst Rev 2009; :CD007076.
  72. Straube S, Derry S, Moore RA, McQuay HJ. Pregabalin in fibromyalgia: meta-analysis of efficacy and safety from company clinical trial reports. Rheumatology (Oxford) 2010; 49:706.
  73. Billups SJ, Delate T, Hoover B. Injury in an elderly population before and after initiating a skeletal muscle relaxant. Ann Pharmacother 2011; 45:485.
  74. Heiskanen T, Mätzke S, Haakana S, et al. Transdermal fentanyl in cachectic cancer patients. Pain 2009; 144:218.
  75. Dosa DM, Dore DD, Mor V, Teno JM. Frequency of long-acting opioid analgesic initiation in opioid-naïve nursing home residents. J Pain Symptom Manage 2009; 38:515.
  76. Gupta DK, Avram MJ. Rational opioid dosing in the elderly: dose and dosing interval when initiating opioid therapy. Clin Pharmacol Ther 2012; 91:339.
  77. Bellville JW, Forrest WH Jr, Miller E, Brown BW Jr. Influence of age on pain relief from analgesics. A study of postoperative patients. JAMA 1971; 217:1835.
  78. Kaiko RF. Age and morphine analgesia in cancer patients with postoperative pain. Clin Pharmacol Ther 1980; 28:823.
  79. Kaiko RF, Wallenstein SL, Rogers AG, et al. Narcotics in the elderly. Med Clin North Am 1982; 66:1079.
  80. King S, Forbes K, Hanks GW, et al. A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project. Palliat Med 2011; 25:525.
  81. Arnstein P. Balancing analgesic efficacy with safety concerns in the older patient. Pain Manag Nurs 2010; 11:S11.
  82. Vadivelu N, Hines RL. Management of chronic pain in the elderly: focus on transdermal buprenorphine. Clin Interv Aging 2008; 3:421.
  83. Dahan A, Yassen A, Romberg R, et al. Buprenorphine induces ceiling in respiratory depression but not in analgesia. Br J Anaesth 2006; 96:627.
  84. Walsh SL, Preston KL, Stitzer ML, et al. Clinical pharmacology of buprenorphine: ceiling effects at high doses. Clin Pharmacol Ther 1994; 55:569.
  85. Stamer UM, Stüber F. Genetic factors in pain and its treatment. Curr Opin Anaesthesiol 2007; 20:478.
  86. Vella-Brincat J, Macleod AD. Adverse effects of opioids on the central nervous systems of palliative care patients. J Pain Palliat Care Pharmacother 2007; 21:15.
  87. Papaleontiou M, Henderson CR Jr, Turner BJ, et al. Outcomes associated with opioid use in the treatment of chronic noncancer pain in older adults: a systematic review and meta-analysis. J Am Geriatr Soc 2010; 58:1353.
  88. Chey WD, Webster L, Sostek M, et al. Naloxegol for opioid-induced constipation in patients with noncancer pain. N Engl J Med 2014; 370:2387.
  89. Weiner DK, Hanlon JT, Studenski SA. Effects of central nervous system polypharmacy on falls liability in community-dwelling elderly. Gerontology 1998; 44:217.
  90. Zutler M, Holty JE. Opioids, sleep, and sleep-disordered breathing. Curr Pharm Des 2011; 17:1443.
  91. Moore RA, McQuay HJ. Prevalence of opioid adverse events in chronic non-malignant pain: systematic review of randomised trials of oral opioids. Arthritis Res Ther 2005; 7:R1046.
  92. Chibnall JT, Tait RC. Pain assessment in cognitively impaired and unimpaired older adults: a comparison of four scales. Pain 2001; 92:173.
  93. Weiner D, Karp J, Bernstein C, Morone N. Pain Medicine in Older Adults: How Should it Differ?. In: Comprehensive Treatment of Chronic Pain by Medical, Interventional and Behavioral Approaches, Deer T, Ray A, Gordin V, et al (Eds), Springer, New York 2013. p.977.
  94. McLachlan AJ, Bath S, Naganathan V, et al. Clinical pharmacology of analgesic medicines in older people: impact of frailty and cognitive impairment. Br J Clin Pharmacol 2011; 71:351.
  95. Benedetti F, Arduino C, Costa S, et al. Loss of expectation-related mechanisms in Alzheimer's disease makes analgesic therapies less effective. Pain 2006; 121:133.
  96. Lapane KL, Quilliam BJ, Chow W, Kim MS. Pharmacologic management of non-cancer pain among nursing home residents. J Pain Symptom Manage 2013; 45:33.
  97. Pergolizzi J, Böger RH, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract 2008; 8:287.
  98. Andrade DC, Faria JW, Caramelli P, et al. The assessment and management of pain in the demented and non-demented elderly patient. Arq Neuropsiquiatr 2011; 69:387.
  99. Lints-Martindale AC, Hadjistavropoulos T, Lix LM, Thorpe L. A comparative investigation of observational pain assessment tools for older adults with dementia. Clin J Pain 2012; 28:226.
  100. Fuchs-Lacelle S, Hadjistavropoulos T. Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Manag Nurs 2004; 5:37.
  101. Feldt KS. The checklist of nonverbal pain indicators (CNPI). Pain Manag Nurs 2000; 1:13.
  102. Snow AL, Weber JB, O'Malley KJ, et al. NOPPAIN: a nursing assistant-administered pain assessment instrument for use in dementia. Dement Geriatr Cogn Disord 2004; 17:240.
  103. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc 2003; 4:9.
  104. Villanueva MR, Smith TL, Erickson JS, et al. Pain Assessment for the Dementing Elderly (PADE): reliability and validity of a new measure. J Am Med Dir Assoc 2003; 4:1.
  105. Bjoro K, Herr K. Assessment of pain in the nonverbal or cognitively impaired older adult. Clin Geriatr Med 2008; 24:237.
  106. Scherder E, Herr K, Pickering G, et al. Pain in dementia. Pain 2009; 145:276.
  107. Chibnall JT, Tait RC, Harman B, Luebbert RA. Effect of acetaminophen on behavior, well-being, and psychotropic medication use in nursing home residents with moderate-to-severe dementia. J Am Geriatr Soc 2005; 53:1921.
  108. Pharmacological Management of Persistent Pain in Older Persons (2009) http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2009/ (Accessed on January 09, 2014).