Book Review

The book Clinical Management of the Elderly Patient in Pain is an out of the ordinary read. It is edited by Dr Gary McCleane and Dr Howard Smith, both practicing pain clinicians who also contributed a number of the chapters. Other contributing authors are from the United States, United Kingdom and Canada, and represent a variety of fields including anesthesia, geriatrics, psychiatry and physiatry. The book has three introductory chapters on older adult demographics and pain, aging and pain, and pharmacological changes in elders. The main section of the book consists of 12 chapters on different classes of analgesics administered through a variety of routes and preparations, followed by chapters on physical therapy, psychosocial issues and uses of psychotropics. The book finishes with a chapter listing suggested medications for common painful conditions in older adults. There is an appendix of drug interactions as well as a glossary and index. The preface notes that this is not a typical book on pain management and states that it will consider “treatment that may be conventional, but also that which may appear more contentious”. The preface notes how it can be difficult to balance pain relief with side effects and advocates “considering the patient as a whole”. To the editors, this means considering not only treating the pain but also the harms that can come from analgesic side effects, polypharmacy and drug interactions. The audience of the book is the generalist “busy clinician” faced with “all the problems of satisfactorily managing pain in the elderly”. Each chapter has something for those interested in novel therapies for chronic pain. For example, I learned that menthol has analgesic properties mediated through the delta opioid receptor. I also learned about novel uses of topical nitrates for chronic pain. There are detailed descriptions of the evidence behind topical therapies, which in reducing systemic side effects, are certainly of benefit in older adults. The material is presented with enough prescribing information and supporting evidence to make one comfortable with trying these medications on patients. The editors remain true to the preface in considering the effects of the analgesics and their side effects but this information is not organized in any consistent fashion throughout the book. As indicated in the preface, only a short part of the book is dedicated to discussion of opioids. Some statements in the relevant chapter do stand out and merit mention. There is a statement that the development of analgesic tolerance is quite common in opioids but there is no evidence provided, contrary to most of the book. However, there is evidence that opioid tolerance is quite low (1). As well, a study is quoted as noting the increased risk of nonspine fractures in older women taking opioids (2). This same study shows an even higher risk of nonspine fractures for older women taking antidepressants, a drug class that is recommended throughout the book. The chapter author does say that his overall opinion – that opioids should used only in a limited fashion in chronic pain in elders – is based on his past experience. The evidence for the use of opioids is increasing (3,4); with systematic reviews showing a number needed to treat of 2.5 (5) and studies showing sustained improvement and no significant increase in adverse effects even in frail older adults (6). Increasingly, it is becoming apparent that there may be better opioid choices in frail elders and in renal failure (7,8). One of the best chapters is on psychosocial issues and provides useful and practical help to clinicians. The chapter on use of psychotropics also provides practical information as well as the principle of treating both the symptom and the person. There are other titles of related interest in the Haworth Series on Clinical Pain and Symptom Palliation that likely go into much greater detail on psychological and spiritual issues and nonpharmacological management of pain that would likely provide much greater depth in these areas. One of the major challenges in managing pain in older adults is the issue of pain management in those with cognitive impairment. Unfortunately, the only significant mention of cognitive impairment is with respect to side effects from medication as opposed to the difficulties of assessing and titrating analgesics in those with severe dementia who cannot contribute any meaningful history. The demographics of older adults, their need for improved pain management and the pharmacokinetic alterations in this population are key points that everyone needs to understand to manage pain in this population. However, these points are repeated in a number of chapters as if these were all written separately and not edited as a whole. The writing style is variable and at times faulty, which can distract from the useful content. A more detailed index would help clinicians to retrieve useful medication suggestions during a busy office. The preface noted that this book is intended to act as an interface between the specialist pain practitioner and busy generalist clinician trying to manage older adults in pain. However, many generalist clinicians are still needing to build the basic principles of pain management into their practice and need simpler, more directive tips about pain assessment and reevaluation, diagnosis, and considerations around treatment of underlying pathology to manage an older adult in pain. Clinical Management of the Elderly Patient in Pain is a detailed resource for those who are interested in the evidence that supports the use of new and emerging medications and routes of administration. I believe this book would be of interest to the generalist physician who has a special interest and experience in pain management and is able to read the whole text and bookmark the excellent suggestions for therapies that might be better tolerated in older adults.

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