Musculoskeletal Pain, Geriatric

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Diagnosis and reasoning

This lady suffers from chronic musculoskeletal pain, which is common in older adults and is associated with significant morbidity, including depression, social isolation, sleep disturbances, and decreased ambulation. Its management can be complicated by ongoing treatment for multiple comorbidities. The objectives of her initial assessment are as follows: - Distinguish common musculoskeletal pain from serious visceral or non-rheumatic pain - Identify comorbidities that may influence the management or mimic musculoskeletal pain - Recognize any concurrent psychosocial issues In this lady's case, axial pain on physical activity with a loss of function, crepitus on active movements, and the short duration of morning stiffness all strongly suggest osteoarthritis (OA). The history of preceding severe OA the hips necessitating joint replacement further supports this diagnosis. Radiography, the assessment of choice for suspected rheumatological conditions, confirms severe osteoarthritic changes of the shoulder joints, lumbar spine, and both knee joints. While MRI would provide further details, it is unnecessary at this point, and unlikely to affect the management. A DEXA scan may be considered for patients with suspected osteoporosis, which is not the case here. Arthroscopy is not indicated, either. Her management should ideally be multifaceted, incorporating both non-pharmacological and pharmacological approaches. In this respect, as the pain has been unresponsive to acetaminophen, the first-line analgesic for her condition, and NSAIDs would increase the risk of bleeding, steroid injections are an option. Furthermore, physiotherapy is key to increase the range of movement and improve her overall quality of life. Knee replacement is an option if conservative management fails, or if she requests surgery.


Discussion

Chronic geriatric pain may be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, for a duration of over three months, in aged (65 to 79 years old) or very aged (80 and over) persons. It is the most common form of nonmalignant geriatric pain. Research is sparse and the condition itself largely underreported, due to sociocultural issues and commonly held misconceptions. However, it is known that the prevalence rises with age till about 65 years and then stabilizes. There is no single pathophysiology, as musculoskeletal pain can be caused by a wide array of conditions. Common factors at play include tissue injury, local ischemia, spasms, myositides, and abnormal posture. Etiologically, chronic geriatric pain can be classified as rheumatic or non-rheumatic. Osteoarthrosis is the most common rheumatic condition; previous fractures and myofascial pain syndromes are other well-known causes. Neurodegenerative diseases such as Parkinson's disease may also lead to a musculoskeletal pain syndrome. The initial assessment of these patients should focus on excluding serious non-rheumatic causes, detecting comorbidities, and identifying concurrent psychosocial issues. Note that pain is a complex clinical manifestation that is perceived differently from person to person. This is especially complicated in the elderly, due to the prevalence of multiple comorbidities, ongoing polypharmacy, cognitive impairment, and psychosocial issues. Yet, a thorough history of the location, duration, nature, intensity, and aggravating and alleviating factors, followed by a detailed physical exam, can lead the judicious clinician to an accurate diagnosis. Pain in the hips, knees and lower back is commonly due to osteoarthritis or past surgery, while pain and muscle tightness in the neck, back, and legs, along with dystonia of the foot, is typical of Parkinson's diseases. Chronic pain is perceived at multiple sites. Additionally, patients should be screened for depression, cognitive dysfunction, gait abnormalities, sensory deficits, and the impact of the illness on their activities of daily life (ADL's). Conservative management may be employed for a reasonable period prior to running tests if a serious condition is not suspected. In the event that red flag symptoms are present, investigations should include a full blood count, C-reactive protein, and erythrocyte sedimentation rate. Plain radiography of the affected sites is generally sufficient to identify rheumatological conditions. CT and/or MRI may be required in the presence of red flag symptoms. A multidisciplinary approach is recommended for treatment, consisting of both non-pharmacological and pharmacological therapies. Educating the patient and their family is vital, as is an evaluation of the available social support. Acetaminophen is the first-line analgesic for musculoskeletal pain in older adults. Non-steroidal anti-inflammatory drugs (NSAIDS) and cyclooxygenase-2 (COX-2) inhibitors, although potentially more effective, are only used when safer alternatives are not tolerated or ineffective, to avoid gastrointestinal, cardiovascular, and renal toxicity. Opioids, such as morphine and fentanyl, are recommended for severe, incapacitating pain. However, judicious use is advocated in view of their psychoactive nature and potential for addiction and fatal overdose. Involving a pain specialist ensures better pain management and a possible reduction of the dosage of analgesics if an interventional technique is employed; nerve blocks are most commonly utilized in this regard. Other useful procedures are chemical neurolysis, radiofrequency ablation, epidural injections, adhesion lysis, intraarticular injections with steroids or hyaluronic acid, sympathectomy, and spinal cord stimulation. Note also that psychological therapies are extremely useful, particularly so for patients with depression. This may include cognitive behavioral therapy, meditation, and relaxation techniques.


Take home messages

  1. Musculoskeletal pain is the most common form of nonmalignant pain in the geriatric population.
  2. Careful assessment is crucial, as such patients often have coexisting illnesses, psycho- cognitive alterations, social problems, and polypharmacy, which may impact the management.
  3. Treatment consists of the combined use of non-pharmacological and pharmacological therapy.
  4. Paracetamol is the preferred initial analgesic, although NSAIDs or interventional pain management may be required.

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