1. Discuss management of pain in the elderly – what are the particular concerns?  What meds are available (including their risks and benefits)?  What different modes of administration might be considered?

According to the World Health Organization (WHO) chronic geriatric pain is a common problem faced by healthcare providers therefore a guideline for pain management was established. Who recommends to

1. Giving drugs ‘‘by the clock’’- schedule dosing
2. By mouth (oral route)
3. Following ‘‘analgesic ladder’’
   1. Mild pain – acetaminophen.
   2. Mild to moderate pain or pain uncontrolled with acetaminophen – NSAIDs.
   3. Pain refractory to NSAIDs – weaker opioid agonist.
   4. For pain refractory to the previous plan, or severe pain – pure opioid agonist.

 

Oral Pharmacologic Therapies: selective and nonselective NSAIDs, acetaminophen, tramadol, and opioid analgesics.

 

• Acetaminophen–
  • According to American Geriatrics Society (AGS), acetaminophen should be used as a first-line agent for mild- moderate chronic pain in elderly. AGS recommends acetaminophen use because it is inexpensive, safe and effective. One of the most concern regarding acetaminophen is hepatotoxicity especially among alcohol abuser patient
• Oral NSAIDs
  • NSAIDs acts as an analgesic and anti-inflammatory effect so it is very useful for pain management for OA patient especially those who minimally respond to acetaminophen alone and with moderate-to-severe levels of pain. Because of the efficacy of the NSAIDS most elderly patient prefer NSAIDS over acetaminophen in managing pain. However, most common complications are GI complications such as peptic ulcer and bleeding. CKD patient in stage IV or V t are recommended to avoid NSAIDS and cardiovascular disease patient have increased risk of MI or stroke. Due to the side effects profile, AGS recommends older adults avoid or use great caution using NSAIDS for the treatment of chronic persistent pain.

 

• Narcotic analgesics
  • Tramadol is a weak μ-opioid that can effectively relive pain elderly patient especially severe chronic pain, OA pain in the hand, knee or hip. Tramadol is a narcotic agents and most common side effects are nausea, dizziness, somnolence, and vomiting. Long-term use may also lead to physical dependence
  • Stronger narcotic medicines, such as oxycodone, hydrocodone, ormorphine sulfate, may be considered in patients after failure of other treatments.

 

Topical Agents- can be found in creams, gels, patches which can be use as alternative or adjunctive agents

• Topical capsaicin
  • Topical Capsaicin is effective in treating hand OA pain because it the cream contains lipophilic alkaloid extracted from chili peppers which activates and sensitizes peripheral c-nociceptors.
• Rubefacients
  • Rubefacients containing salicylates may also be used as adjunctive agents for and hand knee OA pain. most common side effects are skin burning, stinging, and erythema.
• Topical NSAIDs
  • Topical NSAIDs such as diclofenac sodium gel is an effective alternative to oral agents. Particularly helpful in treating hand and knee OA. GOOD safety profile so it can be used in cardiac, renal and GI comorbidities patient profile.
• Topical lidocaine:
  • The 5% lidocaine can be used for postherpetic neuralgia or other neuropathic pain conditions, but it can cause mild skin irritation

 

Injectable intraarticular:

corticosteroids, prolotherapy, and hyaluronic acid-based medications

 

2. What is the role of rehabilitation in osteoarthritis in the elderly?

Most common rehabilitation practices include:  Kest, exercise, heat, cold, drugs, injection, surgery, and complementary medicine all have important roles. Most providers suggest rehabilitation to begin early in the course of the disease because rehabilitation can delay or prevent the onset of functional decline and disability. Osteoarthritis patient really benefits from strengthening and aerobics exercise because research has shown it improves function, improve quality of life, and decrease pain (2). Occupation therapy assist in “energy conservation, ADL training, joint protection, and assessment for adaptive devices”. For OA patient, knee bracing devices is a great tool as it enhances proprioceptive feedback, warmth, and stability. Overall, rehabilitation such as physical therapy has shown to reduce pain and improve functionality significantly when compared with intraarticular glucocorticoid injection (3).

 

3. How effective is acetaminophen for knee pain in the elderly (for this you’re looking for fairly recent articles – last 3-4 years)?

“American Geriatrics Society (AGS) recommends acetaminophen as the first-line agent for mild to moderate chronic pain in the elderly.” Acetaminophen can be used a first line agent in mild to moderate knee pain especially due to osteoarthritis. Acetaminophen most often chosen my provider because it is inexpensive, safe and effective. For osteoarthritis and back pain Acetaminophen is effective at relieving symptoms however, for chronic inflammatory pain (such as rheumatoid arthritis) NSAIDs is more effective than Acetaminophen.

Sources:

1. Vina ER, Kwoh C. Osteoarthritis. In: Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Supiano MA, Ritchie C. eds. Hazzard’s Geriatric Medicine and Gerontology, 7e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.york.ezproxy.cuny.edu/content.aspx?bookid=1923&sectionid=144562421. Accessed April 30, 2020.

 

2. Hata J. Arthritis: Rheumatoid, Osteoarthritis, Crystalline Arthropathies, and Seronegative Spondyloarthropathies. In: Mitra R. eds. Principles of Rehabilitation Medicine New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.york.ezproxy.cuny.edu/content.aspx?bookid=2550&sectionid=206766733. Accessed April 30, 2020.
3. https://www.2minutemedicine.com/physical-therapy-reduces-pain-in-adults-with-knee-osteoarthritis/
4. Ali, A., Arif, A. W., Bhan, C., Kumar, D., Malik, M. B., Sayyed, Z., Akhtar, K. H., & Ahmad, M. Q. (2018). Managing Chronic Pain in the Elderly: An Overview of the Recent Therapeutic Advancements. Cureus, 10(9), e3293. https://doi.org/10.7759/cureus.3293