Publications
APS Bulletin • Volume 17, Number 2, 2007
Resource Reviews
John D. Loeser, MD, Department Editor
Clinical Management of the Elderly Patient in Pain
Reviewed by Debra K. Weiner, MD
Gary McCleane, Howard Smith (Eds.), Binghampton, NY, The Haworth Medical Press, 2006. Soft cover, 304 pages, ISBN 0-7890-2620-1, $34.95.
Clinical Management of the Elderly Patient in Pain may or may not help practitioners improve pain management. Pain is an extraordinarily complex clinical phenomenon contributed to by heterogeneous and multifactorial pathological disorders that in turn are modified by numerous nonphysical factors such as impaired neuropsychological and physical function, social isolation, sensory deprivation, and restricted financial resources. Older adults are not simply a chronologically older version of younger patients with pain and the need for McCleane and Smith’s book is inarguable. Determining who may benefit from the material that they present, however, is problematic.
To be fair, the book contains an abundance of detailed information on pharmacology, including some interesting information on topical preparations. In fact, the vast majority of the book focuses on drugs. Thus, for practitioners who are confident in their diagnostic skills and are certain that medications are a necessary part of their older adult patient’s treatment regimen, the book may be helpful.
As much as the plethora of detailed information about pharmacology represents one of the book’s strengths, it is also a weakness. More than any other age group, older adults are at risk of significant morbidity and mortality from adverse drug reactions. Some would argue that systemic analgesics should be considered as a last resort in older adults and used only as a means to facilitate rehabilitation therapy. To the authors’ credit, alternative, less toxic routes of medication administration (e.g., topical, spinal) are presented, but this does not balance the overall focus of the book on oral analgesic therapies. The chapters on physical therapy and psychosocial factors are a welcome addition, but even the physical therapy chapter is biased toward medications, stating that “a pharmacological approach to pain management in older people is necessary but insufficient on its own.”
Proper assessment holds the key to proper treatment. As a practitioner who cares for older adults in a tertiary referral center, I am aware that one of the biggest barriers to effective pain management lies in misguided diagnostic strategies because of inadequate education and training about the common painful conditions from which older adults suffer. Unfortunately, the book provides no assessment guidelines.
How then might the average practitioner faced with an older adult patient in pain actually use this book? A summary table in Chapter 19, Treatment of Common Conditions, is provided to guide treatment approaches to already diagnosed disorders. Inadequate detail and contradictory information, however, make this table difficult to use. For example, the guidelines suggested for the treatment of diabetic peripheral neuropathy: The target dose of gabapentin is stated as 900–2,400 mg/day, but titration guidelines are not provided. Amitriptyline is listed as the tricyclic antidepressant of choice, even though Table 11.1 on p. 119 provides information that implies amitriptyline is relatively contraindicated in older adults because of its extreme anticholinergic potential.
Another way to use the book is to start with the index. When one does so, however, often numerous page numbers are provided for any one entry. In the case of propoxyphene, there are only two page numbers. On p. 39, we learn that propoxyphene may have cardiotoxic effects. On p. 204, we learn that this drug is “an agent generally not advised to be administered in the elderly.”
Another concern is that although the title of the book indicates that this volume specifically discusses management of pain in older adults, much of the information is presented in a generic way or using an academic rather than a clinical framework, thus making it difficult for practitioners to use. For example, methadone is mentioned as a “safer analgesic than the other strong opioids in those with renal impairment,” while methadone has an extremely long and variable half life. For the inexperienced practitioner, methadone may be very tricky to use, but titration guidelines are not provided. Another example is the discussion of mobility risks associated with opioids. They state, “When considering the effects of opioids on cognitive and motor function, it seems clear that stable use of sustained-release preparations such as controlled-release morphine and transdermal fentanyl are not associated with impairment of cognitive or motor performance.” The origin of this statement is not provided, and does not reflect clinical practice.
Future editions of Clinical Management of the Elderly Patient in Pain will be greatly improved by more careful editing to prevent redundancies and eliminate inconsistencies and by expanding the scope of the volume to reduce deficiencies. Cross-referencing among the various chapters would also be helpful toward the book’s presentation as an integrated volume rather than a compendium of individual essays. This book has the potential to be an important resource for primary care practitioners who are eager to help their older adult patients suffering from pain, but unfortunately not in its current iteration.
Dr. Weiner is Associate Professor of Medicine, Psychiatry & Anesthesiology, and Director of the Older Adult Pain Management Program, University of Pittsburgh.