Dr. Una Makris is an Assistant Professor in the Department of Internal Medicine – Division of Rheumatology who recently published an article in JAMA, “Management of Persistent Pain in the Older Patient – A Clinical Review”. Below is a short Q&A with Dr. Makris as she discusses her article.
Q: Why did you review prior literature and investigate the management of older patients with chronic pain?
This article is focused on the clinical vignette of a medically and psychologically complex 90 year old patient, Mrs. L. Our objective was to provide an overview of barriers to the management of persistent pain in older adults, summarize current pharmacologic, nonpharmacologic, and rehabilitative management options. We also felt it is necessary to review the literature on therapeutic alliance/patient-physician relationship as we feel this is critical to effectively treating pain, in the elderly (and all ages really).
Q: Can you summarize the findings of your paper? What was most surprising?
The text boxes, tables and figures summarize key points of our review in the various approaches to managing persistent pain in older adults. What is most surprising, and I know this from my own research and reviews of the literature for older adults with chronic back pain: there is a paucity of data to help guide our clinical decision-making in older adults (often excluded from clinical trials because of comorbidities, polypharmacy, frailty, tenuous social circumstances, etc) who are medically complex. We often extrapolate findings from younger, healthier populations and hope this will be appropriate for our older patients. Similarly, we find studies on depression or chronic pain or cognitive impairment (each in isolation) and try to manage our patients with data that may not make sense when “our patient in clinic” has all three issues concurrently. We hope to see more research focused on the medically complex patients we see in the real-world setting.
Q: What are the benefits of using large databases like Cochrane when performing these kind of studies?
Cochrane reviews have pre-determined quality criteria for including specific trials, potentially reducing bias. I find it most helpful to skim reference sections of Cochrane reviews; and use the original trial manuscript in my review if possible. For clinical and research purposes, I rarely stop with Cochrane reviews, but find them to be a nice platform to start with.
Q: How do you think your findings will impact the way providers practice? Has it affected the way you practice?
I hope the clinical vignette presented and our review will provide clinicians with confidence to treat/manage older adults with persistent pain (especially those who have “tried it all” and may have a “been there, done that” predisposition) with a multimodal approach. I am a strong believer that medications alone are not the solution to chronic pain issues, so investing in the non-pharmacologic (especially behavioral interventions) and rehabilitative management approaches is critical, especially in older adults. Our review has impacted the way I approach my older patient with persistent pain— perhaps I am now a little more persistent— trying to target outcomes that matter most to them! We can learn a lot about our patients when we ask about treatment goals and expectations.
Click on the link below to read the article: