Treatment of chronic pain in the elderly

| The treatment of chronic pain, due to its important functional and psychological repercussions and on the quality of life of patients, should be a priority for the geriatric patient care team.

It will be a priority to apply all possible measures to control and alleviate the chronic pain through existing resources. To obtain good results (maximum benefit / minimum risk) a work system is necessary in terms ofpain assessment in the elderly and their subsequent treatment, which allows designing a treatment tailored to each patient.

In the elderly patient, due to its special characteristics (changes due to aging, multiple pathologies, polypharmacy, psychological disorders, etc.), the control and management of chronic pain it is a complex issue.

The basis of pharmacological treatment is preferably the oral route, following the analgesic ladder. Although elderly patients are more predisposed to the side effects of painkillers, experience shows that they are safe and effective at this stage of life.

For certain analgesics, especially opiates, the elderly show an increase in analgesic effects. Due to the variability presented by this group of patients, it is difficult to establish protocols in terms of dose and side effects, so it is essential to establish an individualized treatment, with logic and common sense, following the advice of the American Geriatric Society of " start slow and continue slow ”to assess the results, both pain relievers and side effects.

The potency of analgesics will be determined by the intensity of the pain and never by the estimated survival of the patient. The combination of different drugs with analgesic properties in small doses may be necessary to increase the analgesic effect and decrease the side effects.

At sharp pain Of short evolution, minor analgesics are usually used (paracetamol or anti-inflammatories such as ibuprofen, metamizole, etc.), as long as the intensity allows it. In view of chronic pain of high intensity One should not hesitate to use opioid drugs (lesser such as codeine and tramadol, or greater such as morphine or fentanyl), since they are safe when prescribed in a controlled way and knowing the side effects they present (constipation, dry mouth, drowsiness, etc.). All of this is the basis of the so-called analgesic ladder.

The analgesic ladder, promoted by the WHO, is a guideline for increasing the potency of analgesics to be used as the intensity of pain increases and that can be summarized as follows:

• In view of moderate pain or at first, non-opioid analgesics are recommended, such as paracetamol, anti-inflammatories, metamizole, etc., associated or not with so-called adjuvants, which are drugs that modify the response to pain, which are very useful in the case of neuropathic pain ( antiepileptics, antidepressants).
• In case of no control or moderate to severe pain, minor opioid pain relievers, such as codeine or tramadol, can be used. They are used alone or in combination with anti-inflammatories or adjuvants, which allows the use of lower doses of the drugs (but with a higher risk of interactions).
• The next step, in case of uncontrolled or already high initial intensity, major opiates (morphine, fentanyl, buprenorphine, oxycodone, methadone) should be used; these can also be associated with other pain reliever drugs. These drugs can be used orally, subcutaneously, transdermally (patches) and even by infiltration into the nerve roots, alone or in association with local anesthetics.

There are non-pharmacological physical therapies, such as transcutaneous nerve stimulation, in which the increase in sensory afferent flow in certain circumstances is capable of reducing pain. Electrode stimulation is performed in the painful area for about ten minutes. If effective, the pain is replaced by heat or a tingling sensation. The duration of relief is variable.