Assessing pain is essential to handle its management. The history requires documenting the patient’s own words, and asking several times about the pain. It is the pain acute chronic or cancer? Are there other factors affecting the pain, as heart, kidney, liver, or chest diseases. These factors can make it difficult in managing the patients activities and pain levels. The best advice is to start with low levels and go slow observing the patient’s tolerance levels.

Acute pain requires analgesic interventions Opioid drugs are used to treat postoperative or acute pain but in a frail person, these drugs may cause confusion. The older patient seems to need the same treatment as the younger one. Doctors are afraid that treating the pain in an older person may result in hastening his death.

In chronic pain, one must change the individual’s thoughts and beliefs about their pain and give them the skills to take more control of their pain. Older patients may have problem with cognitive abilities and often have liver, kidney, heart or chest diseases

Lacking social support, and having some memory and sensory losses, prevent them from participating in group therapy

Inadequate treatment of pain in the elderly results in harmful reactions as functional impairment, falls, slow rehabilitation, mood changes, decreased socialization, sleep and appetite disturbances, and greater health care use and costs. Persistent pain can be very distressing for both the patient and caregiver.

The best indicator of pain is the patient’s own words. Pain evaluation can be difficult when cognitive impairment exists. The pain should be managed to a level that allows the patient to engage in activities. This requires doctors to be knowledgeable of the drugs they prescribe and their harmful effects.

Muscle relaxants are often prescribed.
cyclobenzaprine.(Flexeril). It failed as an antidepressant and was repackaged as a muscle relaxant. It is very similar to amitriptyline and differs only by a single double bond. Both have a risk for sudden heart death, have anti-cholinergic side effects and are sedating.. Despite being prescribed as muscle relaxants, They act as antidepressants.
carisoprodol,( Soma). It is banned in Europe because of its addictive qualities. It metabolizes as meprobamate ( Miltown) a sedative-hypnotic which when overused, results in emergency room visits.
methocarbamol,( Robaxin), and metaxalone, (Skelaxin) have been use for 30 years should be considered despite producing some sedation.
orphenadrine,(Norflex) Acts like Benadryl and can produce motor impairment and Acts as a sedative when used with alcohol.
tizanidine ( Zanaflex) It is not officially approved as a muscle relaxant, but is used to treat spasticity. When combined with ibuprofen ( Motrin), it works well in chronic and acute musculoskeletal and neuropathic pain. Having a half-life of 1 ½ hours, there is no hangover effect. It is often used at night to help produce a more comfortable sleep, reduce spasm, and wake up feeling refreshed.
baclofen,(Lioresal). It is also marketed for spasticity. It has a sedative property and should be monitored closely.

Other complementary medical therapies as topical or other anti-inflammatory drugs for painful muscle spasms along with acupuncture and therapeutic exercise, can make muscle relaxants more effective. Many older people use complementary therapies for pain relief. They use relaxation techniques, herbal medicine, food supplements, chiropractic, acupuncture, and massage.

Specific modalities are used for specific reasons as musculoskeletal pain and acupuncture or herbal remedies and depression. These alternative treatments can be dangerous when using manipulation. Electoral stimulations by transcutaneous electric nerve stimulation allows the patient to have some control over their pain. Tens units however can be difficult for older people to use when the dials are not clearly marked. Tai chi and Yoga exercises can improve flexibility and prevent falls.

There are no recommended age adjusting dosages for most analgesics. sold the patient has started a little bit careful titration. Optimum dose and common side effects are hard to predict.

Chronic cancer pain is more frequent now since over two thirds of people with cancer are expected to live at least five years and their 10 year survival is approaching 60%. Since there are 12 million people with cancer today, surviving patients with advanced cancer much pain relief help is needed. Many have physical limitations, are depressed and anxious, have trouble sleeping and are tired, have sexual dysfunction, cognitive problems, and have a great deal of pain.

Cancer survivors limit their visits to their oncologists after their cancer treatment and their needs are often handled by primary care doctors. Treatment related pain is their long-term issue. The longer survivors live, the more their pain becomes chronic rather than acute, and their pain management must be handled differently. In clinical trials, effective cancer drugs were never measured for side effects. The patient’s hate to admit there are even having side effects because they would be dropped from a treatment trial.

Side effects of chemotherapy, radiation therapy, hormonal therapy, graft related problems, and surgery related pain are often not addressed. The multiple neurotoxic agents and chemotherapy and radiation have resulted in intense paresthesias, numbness of hands and feet, and burning. Their symptoms resemble diabetic neuropathy.

Numerous drugs as anticonvulsants, antidepressants, and serotonin inhibitors as:
amitriptyline, nortriptyline gabapentin, pregabalin duloxetine, venlafaxine have not been effective. Because of spatial orientation problems, they are at risk for falls and other injuries. Throw rugs must be eliminated, night lights used, and their walking surfaces be nonskid. If their hands are numb, hot water temperature should be turned down to prevent burns. Good foot care is also required.

Radiation problems have killed nerves in the treatment area especially in the armpit. Breast cancer patients develop pain radiating down their arms. GYN cancer and colon cancer patients suffer back pains affecting their legs.

Symptoms are often delayed for months and even for a year or two. Armpit problems begin with numbness and tingling of the hands and fingers followed by weakness and pain. Back pain symptoms begin with bilateral leg weakness, muscle twitching, numbness, tingling, and sometimes chronic pain radiating down the leg or arm. It is often necessary to evaluate possible tumor recurrence before treatment. These pains greatly undermined the quality of life since they are severe and disabling. Effective treatments for these pains card not being addressed. Drugs prescribed for relief rarely work and have never been systematically tested.

Women with hormonal positive breast cancer receive aromatase inhibitor therapy after tamoxifen. Since the treatment reduces breast cancer recurrence and prolong survival, this inhibitor therapy is the standard of care. After two months to two years, many women develop joint and muscle pains that resemble arthritis without inflammation. The inhibitors mimic menopause by blocking estrogen production, leading to joint and back pains and stiffness has seen in menopause. There is increase bone breakdown osteoporosis, and reduced bone formation. Symptoms include pain and stiffness in the hands fingers knees hips lower back shoulder feet, difficulty sleeping, tight rings on the finger, difficulty closing the hands and difficulty dressing driving and typing. Treatments include acupuncture, exercise, acetaminophen, nonsteroidal anti-inflammatory drugs, opioids, glucosamine/chondroitin, omega-3 fish oil, and probiotics. Changes in the lifestyle became necessary including regular exercise, and weight reduction. Muscle strength exercises help improve posture and flexibility,.

Hematopoietic Stem cell transplantation (GVHD) , (Graft vs Host Disease-Related Pain) is a new serious pain problem. Skin changes occur like scleroderma, with the skin becoming hard and tight. The eyes are usually affected, but any mucous membrane as the vagina or bowel can be affected. The cancers are potentially cured, but the patient is left with this painful condition. When it occurs within the first three months, it affects the mouth skin eyes, liver and lungs. When it occurs after 3 to 4 months, different skin conditions occur mimicking scleroderma, lichen planus, ichthyosis, and keratosis. The skin itches, becomes infected, and ulcers occur., causing scarring that limits mobility. Chronic, significant organ involvement may occur resulting in the associated pain. Treatments usually include noneffective topical cortisone, and IV opioid drugs.

Despite conservative breast surgery with axillary node dissection, often severe post mastectomy pain results . Patients who receive tissue expanders and reconstructive surgery after the healing process develop paroxysmal pain with burning, and a tight construction in the armpit or upper arm while doing daily chores. Some develop phantom breast pain, others rib pain, neuromas, scar pains and other nerve injuries.
After chest surgery, persistent rib pain occurs from rib retraction, and cut latissimus dorsi and serratus anterior muscles. When a limb is removed for cancer, there are physical sensations painful known as phantom limb pain (PLP). After head and neck cancer surgery, patients develop facial muscle pain, shoulder pain, and sometimes loss of sensations.

Most chronic pain treatments are not effective. The patient may be medically cured of his disease, but the sequelae of pain is often not addressed. Band-Aid treatments for symptoms are used, and eventually the quality of life is destroyed.

Acupuncture has a positive role in paresthesias postoperatively, scar tissues are softened, phantom limb nerves are untangled, and the use of pain medication is often reduced. Above all, the patient must not be deserted after treatment and he given options that can minimize the pain they are experiencing.
When pain occurs, it tends to be constant and moderately severe. There are no standard approaches for treating pain in the elderly. We must not label pain as an inevitable part of aging.

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