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Chronic pain existing without any organic explanation or with an explanation insufficient to account for the degree of pain and disability.
The presenting complaint may be headache, low back, atypical facial, pelvic, or other pain. Some organic component (eg, degenerative arthritis of the spine in chronic lumbar pain) also is usually present. These pains are unequivocally experienced, but psychologic factors predominate in their genesis. The term chronic nonmalignant pain syndrome is a general appellation for these conditions, which implies considerable associated disability (see CLASSIFICATION, above).
From the start, the therapist must recognize the interrelatedness of physical impairment and psychologic state. While psychologic consultation is often needed, the nonspecialist can use principles of behavioral psychology to reduce the abnormal illness behavior and enhance function. The patient should keep a diary, recording the activities performed and the pain experienced (on a scale of 0 to 10) every hour during selected periods. Specific recommendations for increasing activity should be made that are contingent on time rather than on pain. If pain is limiting, the amount of activity can be reduced and again be made contingent on time. The goal is to reduce the intense focus on symptoms and provide the patient with functional goals that can be achieved.
Simultaneously, maladaptive behaviors can be addressed with specific suggestions for gradual change; eg, for social withdrawal, a telephone call to a friend may be prescribed first, followed by a once-a-week outing, then by a visit to a senior center, and so on. The cooperation of the elderly patient may be difficult to obtain, but repeated interventions may yield small changes, with self-reinforcing cumulative improvement. Interventions aimed at similar maladaptive behaviors on the part of others in the patient’s environment may be useful; eg, advising family members or caregivers to encourage the patient to perform self-care activities and not to constantly ask the patient about pain, which only adds to the patient’s ruminations.
Attempts to provide pain relief should not be neglected; nonpharma-cologic methods should be stressed. Cognitive approaches (eg, relaxation training and distraction), transcutaneous electrical nerve stimulation and counterirritation, trigger point injection, spray-and-stretch techniques, and physical therapy may all be useful. Therapy with an NSAID and perhaps a tricyclic antidepressant may help. Opioid therapy is occasionally considered in responsible patients willing to conform to strict management guidelines (see TABLE 12-6). Patients with profound abnormal illness behavior often benefit from referral to a pain clinic, which applies the same principles with greater resources.

Persistent painful dysesthesias can complicate a lesion at any level of the CNS. In the elderly, such central pain usually follows a stroke; the thalamic syndrome is the best example (unilateral dysesthesias, often accompanied by sensory loss and sometimes by weakness and abnormal involuntary movements, occurring after a vascular insult to the contralateral thalamus). Lesions can be too small to be detected with current imaging techniques, and the diagnosis often depends solely on clinical criteria.
Pharmacologic treatment of central pain is similar to that of postherpetic neuralgia. Maintenance of activity, physical therapy for retaining the function of affected extremities, and treatment for concomitant psychologic disturbances are essential. Peripheral neurostimulatory techniques are seldom useful since the pain is diffuse (often throughout half the body), although deep brain stimulation has been used in specialized centers. Neurolytic techniques are not useful.

This disorder is believed to be caused by cross-compression of the proximal part of the trigeminal nerve (usually by an aberrant blood vessel), because an offending lesion is usually identified during surgery and its removal or mechanical protection of the nerve is followed by pain relief. Other causes, including multiple sclerosis, are relatively rare, especially in the elderly.
Medical treatment of trigeminal neuralgia is usually successful. Car-bamazepine and baclofen have been effective in controlled studies; the other anticonvulsants described above and mexiletine are used in patients who fail to respond to these agents or cannot tolerate them. Patients for whom drug treatment fails are candidates for an invasive procedure. Trigeminal gangliolysis by a radiofrequency lesion or by injection of glycerol or other neurolytic solution provides relief to about 80% of these patients for at least a year. Glycerol injection is now considered the safest of these procedures. Suboccipital craniectomy with microvascular decompression of the trigeminal nerve has a similar success rate but is a major operation requiring general anesthesia.

In addition to the pharmacologic approaches described above, splinting (eg, a nocturnal wrist splint for carpal tunnel syndrome) and, occasionally, injection of a local anesthetic and a corticosteroid into the site of compression may benefit these neuropathies. Oral corticosteroids (prednisone 60 mg daily tapered over 1 to 2 wk) are used for acute carpal tunnel syndrome, although no controlled studies support this course. Surgical release of the median nerve is considered the treatment of choice in the elderly patient with chronic carpal tunnel syndrome.

Diabetes is the most common cause of neuropathic pains. Diabetic polyradiculopathy, a subtype of which is diabetic amyotrophy, can cause excruciating pain along multiple nerve roots, usually lumbar, at times accompanied by weight loss and lassitude suggestive of underlying malignancy. The pain is usually self-limited. In contrast, painful diabetic polyneuropathy is characterized by dysesthesias of the feet and calves that may be persistent and intractable.
The acute pain of diabetic polyradiculopathy can usually be managed with opioid drugs. Adjuvant analgesics are considered if the pain persists for more than several weeks. The diagnosis usually is reassuring to the patient, and the severe pain is self-limited.
Chronic painful polyneuropathy is a far greater management problem. Psychologic interventions should be considered early to maintain activity and prevent abnormal illness behavior. Pharmacologic management is similar to that of other continuous neuropathic pains (see above). Occasionally, patients may benefit from the application of transcutaneous electrical nerve stimulation to both calves.

Persistent pain following resolution of acute herpes zoster. The pathogenesis of this pain is unclear but is presumed to involve central reorganization of afferent neural pathways. Persistent pain is present 1 yr after onset in 50% of patients 70 yr of age. Precisely when the pain of acute zoster neuralgia becomes postherpetic neuralgia is controversial and has been variably defined as from the time of lesion clearing to 6 mo. About 2 mo after the onset of the acute disease, treatment should be directed specifically to postherpetic neuralgia.
Primary prevention of postherpetic neuralgia may become possible with widespread use of a varicella vaccine. In patients with acute herpes zoster, corticosteroids and sympathetic blockade have been tried for prevention, but their efficacy has not been confirmed. However, the data suggest the following management scheme.
Immunocompromised patients who develop acute herpes zoster should be treated with antiviral agents (usually acyclovir); these agents prevent viral dissemination and reduce acute pain but have not been shown to reduce the incidence of postherpetic neuralgia. Immunocompetent patients with very severe eruptions, corneal involvement, or intense pain that has not responded to an opioid should also be considered for acyclovir therapy. If the pain is severe and does not respond to NSAIDs or opioids, corticosteroids (eg, prednisone 60 mg daily tapered over 2 wk, or longer if pain flares on dose reduction) can be administered in immunocompetent patients. Sympathetic block with a local anesthetic may also help reduce the pain of acute herpetic neuralgia. Other drugs that have been reported to clear the rash or reduce acute pain include amantadine 100 mg orally bid, levodopa, and adenine monophosphate. The risk:benefit ratio of levodopa and adenine monophosphate in the older patient is unknown, and they are not recommended. The data for amantadine are limited to a single study, and its role remains undetermined. The pain of acute herpetic neuralgia should be managed with NSAIDs and opioids, and local skin care is important.
For postherpetic neuralgia, the mainstay of pharmacologic therapy is an antidepressant. Controlled trials with amitriptyline and maprotiline have been conducted, but as noted anecdotally, some of the tricyclic antidepressants (eg, desipramine) appear to be better tolerated than others in the elderly. Oral local anesthetics, specifically mexiletine, are often used as second-line agents. Patients whose pain has a prominent lancinating component may benefit from the addition of an anticonvulsant. Dosing guidelines for these drugs are described above. NSAIDs appear to have little effect on this and other neuropathic pains, but they help occasionally and are reasonable to try. Opioid therapy is controversial but may ameliorate the pain in some patients. Trials of topical capsaicin and topical local anesthetic (specifically EMLA—eutectic mixture of lidocaine and prilocaine) should be considered despite modest supporting data.
A neurostimulatory technique, usually transcutaneous electrical nerve stimulation, and physical therapy for prevention of secondary myofascial complications should be considered, particularly if the pain affects an extremity. Psychologic interventions are often useful for secondary affective disturbances and abnormal illness behavior. Therapeutic goals should be individualized to restore normal day-to-day function, even when pain relief is incomplete.
Patients with refractory pain should be considered for a trial of temporary sympathetic blocks or subcutaneous injection of a local anesthetic and corticosteroid, although these techniques are supported only by uncontrolled survey data. All anesthetic and surgical neurolytic procedures carry too much risk to be considered except in the most unusual circumstances of profound functional impairment caused by intractable pain alone. The dorsal root entry zone lesion is currently the procedure most accepted.

These syndromes are less common than nociceptive pain syndromes in the elderly. Postherpetic neuralgia, painful polyneuropathies, compressive mononeurqpathies, and trigeminal neuralgia are usually encountered by clinicians; rare causes are central pain, phantom limb pain, pain from root avulsion, and sympathetically maintained pains (eg, reflex sympathetic dystrophy). Adjuvant analgesics are the primary pharmacologic modalities for all of these disorders.

Myofascial pains, common in the elderly, may be acute or recurrent and may conform to clear-cut causes; eg, bursitis, tendinitis, or sprains. Management usually relies on NSAIDs and local injection. Less well characterized is the myofascial pain syndrome, which typically involves painful trigger points in muscle. Pathogenesis is obscure, but the syndrome may be related to overuse of a muscle. Pain may be referred and is usually reproduced by palpating the causative trigger points. These trigger points can be inactivated by injection (dry needling, saline, or local anesthetic) or by a spray-and-stretch technique, in which a vapo-coolant (Fluori-Methane or Fluro-Ethyl) is applied until the skin is numb and the muscle then stretched through a full range of motion. Physical therapy and transcutaneous electrical nerve stimulation may also reduce acute discomfort in these syndromes; continued activity without muscle overuse prevents recurrence.

Degenerative arthritis is the most common cause of nociceptive pain in the elderly (see also Ch. 75). Several specific syndromes may occur. (1) Diffuse and focal joint pain is frequent, but some patients develop pain at only a single joint or bilaterally at only one level (usually, hips), while others develop only diffuse large and small joint pain. (2) Refractory low-back pain may be related to degenerative processes affecting facet joints and the intervertebral space. (3) An often unrecognized syndrome of occipital headache may occur, related to cervical osteoarthritis.
Since both anti-inflammatory and analgesic effects are desirable, NSAIDs are the primary treatment (see NONSTEROIDAL ANTI-INFLAMMATORY DRUGS, above). Occasionally, patients whose pain is virtually continuous or is compounded by sleeplessness or depression will benefit from the addition of a tricyclic antidepressant. Patients with refractory pain can be considered for opioid therapy .
Physical therapy may forestall the development of secondary progressive ankylosis and contractures and also helps prevent inactivity (see TREATMENT OF PAIN AND
INFLAMMATION in Ch. 29). Orthoses (eg, a corset for lumbar pain, a soft collar for occipital or cervical pain, or a knee brace) may be useful.
Injections of local anesthetics and corticosteroids into joints, or into the epidural space for lumbar pain, are widely used despite a lack of well-controlled clinical trials establishing their efficacy. Dramatic benefits are often reported anecdotally, and the procedures should be considered if experienced personnel are available to perform them.
Joint replacement surgery is an option for intractable pain in some joints.

This pain is usually nociceptive. A peripheral lesion activates pain-sensitive fibers, even in patients with mixed syndromes also characterized by a neuropathic component (usually caused by tumor infiltration of nerve trunks) or a prominent psychologic component.
Many cancer pain syndromes have been described . Primary therapy should be directed at the underlying cause, if possible.
Most cancer pain can be managed pharmacologically (see OPIOID ANALGESICS, above).
Patients who fail to respond to pharmacologic management may be candidates for invasive anesthetic, neurosurgical, or neurostimulatory approaches (see TABLE 12-9). In addition, newer techniques of opioid administration (see TABLE 12-5) may be effective (eg, intraspinal administration is commonly used to relieve pain below mid-thorax). All these techniques require the guidance of persons with special expertise.