Advances in understanding the mechanisms and management of persistent pain in older adults † †This article’s contents are solely the responsibility of the authors and do not necessarily represent the official view of the National Center for Research Resources (NCRR) or the National Institutes of Health (NIH). Information on NCRR is available at http://www.ncrr.nih.gov/. Information on Re-engineering the Clinical Research Enterprise can be obtained from http://nihroadmap.nih.gov/clinicalresearch/overview-tr

Abstract

Older adults with persistent pain are not simply a chronologically older version of younger pain patients. Pain-related disability in older adults may be driven by pain 'homeostenosis', that is, diminished ability to effectively respond to the stress of persistent pain. Some of the comorbidities of ageing that can contribute to pain homeostenosis include cognitive and physical impairments, increased sensitivity to suprathreshold pain stimuli, medical and psychological comorbidities, altered pharmacokinetics and pharmacodynamics, and social isolation. A key distinction between older and younger individuals with persistent pain is the normal and pathological ageing-associated brain changes. These may alter the expression and experience of pain with impaired descending inhibition and dysfunction of pain gating mechanisms. Cognizance of these brain changes is needed to guide appropriate evaluation and treatment approaches. This paper reviews data that support these ageingassociated phenomena. Specifically, we discuss age-related changes in the brain (both normal and pathological) and in pain physiology; changes in experience and expression of pain that occur with dementia and contribute to pain homeostenosis; and unique aspects of age and pain-associated psychological function and their contribution to disability. We also present data demonstrating changes in brain morphology and neuropsychological performance that accompany persistent nonmalignant pain in older adults and the treatment implications of these brain changes. Finally, preliminary data are presented on the efficacy of mindfulness meditation, a treatment that has been examined explicitly in older adults and targets optimizing brain function and descending inhibition.

Incorporating Persistent Pain in Phenotypic Frailty Measurement and Prediction of Adverse Health Outcomes

“…Shega and colleagues propose that multisystem dysregulation characteristic of frailty may simultaneously impact pain experience by decreasing ability to modulate pain responses through descending inhibition and coping (3,13). They argue that altered pain experience may explain differences in coping mechanisms and adverse consequences of pain among older compared with younger adults (3,12,13).…”

“…c Reference category is nonfrail class determined by latent class analysis. modulation and processing (3,12,28). Meaningful differentiation of participants into predictive classes suggests the importance of considering persistent pain in frailty measurement.…”

“…Third, persistent pain development can be understood as both cause and consequence of other frailty elements. As reflected in the "pain homeostenosis" theory, multisystem dysregulation may lead to diminished ability to respond to and cope with stressors such as pain, leaving pain unresolved and persistent (12). Frailty-related brain changes may alter older adults' experience of pain by impairing descending inhibition and pain modulation (12,13).…”

“…As reflected in the "pain homeostenosis" theory, multisystem dysregulation may lead to diminished ability to respond to and cope with stressors such as pain, leaving pain unresolved and persistent (12). Frailty-related brain changes may alter older adults' experience of pain by impairing descending inhibition and pain modulation (12,13). In turn, persistent pain often results in impaired mobility, decreased nutritional intake, and social isolation, which may accelerate frailty development (13).…”

Mindfulness meditation in older adults with postherpetic neuralgia: A randomized controlled pilot study

“…Home meditation practice has been associated with improvement in several outcome measures in chronic pain conditions 28 and has been found to be useful for older adults with pain. 29 Because meditation is typically just one component of mindfulness-based stress reduction (MBSR) programs, investigators have recommended that individual program components (e.g., meditation) be evaluated separately 27,30–34 and in samples that are homogeneous regarding the pain condition. 22,28 …”