Documente Academic
Documente Profesional
Documente Cultură
KEYWORDS
Pain Geriatric Congestive heart failure End-stage renal disease Stroke
Opiates
KEY POINTS
Although pain is prevalent among patients living with advanced chronic illnesses, it is often
overlooked and underreported.
Pain is commonly intertwined with other physical and psychological symptoms that lead
to poorer quality of life.
End-organ dysfunction influences treatment of pain in patients with advanced chronic
illnesses.
INTRODUCTION
With advances in medical therapies and improvements in public health, individuals are
living longer and more productive lives. As a result, more older adults are living with
and dying from chronic diseases. More than 85% of Americans 65 years and older
have at least one chronic disease. Many suffer from multiple comorbidities, with an
estimated 11 million older adults living with 5 or more chronic conditions.1 Congestive
heart failure (CHF), end-stage renal disease (ESRD), and stroke consistently rank
among the leading causes of death in the geriatric population.2
Many older adults with CHF, ESRD, or stroke experience pain, which can contribute
to disability and diminished quality of life. Pain from these diseases is often less well
defined and understood than that originating from musculoskeletal (eg, osteoarthritis,
Disclosure Statement: Dr E.L. Siegler receives royalties from Springer Publishing Company. The
other authors have nothing to disclose.
a
Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medical
College, 525 East 68th Street Box 39, New York, NY 10065, USA; b Department of Rehabilita-
tion, Rusk Rehabilitation at New York University Langone Medical Center, 238 East 38th Street
15-62, New York, NY 10016, USA
* Corresponding author.
E-mail address: vep9012@med.cornell.edu
Etiology of Pain
Chronic stable angina
Underlying coronary artery disease is the most common cause of CHF and often leads
to chronic stable angina, as inadequate coronary artery perfusion leads to demand-
induced myocardial ischemia.6 Chronic stable angina symptoms are reported in up
to 29% of patients with heart disease and classically presents as anterior left-sided
chest pain that resolves with rest or nitroglycerin.7 Stable angina is persistent and
chronic over a period of months to years. It is more common for older adults and
women to experience atypical presentations of chronic stable angina, which may
manifest as dyspnea on exertion, sweats, or lethargy.
Noncardiac pain
Although chronic stable angina is a recognized and well-studied entity in cardiology,
literature on noncardiac pain in CHF patients is limited. Widely used quality-of-life
questionnaires in the CHF population, such as the Minnesota Living with Heart Failure
Questionnaire and the Kansas City Cardiomyopathy Questionnaire, do not have ques-
tions assessing noncardiac pain.8,9 However, in one study, 76% of CHF patients
report chronic noncardiac pain, which often goes unaddressed by providers.10
Noncardiac pain in CHF patients is thought to be caused by a combination of compli-
cations from refractory disease (ie, skin breakdown from chronic lower extremity
edema, peripheral ischemia from poor blood flow), underlying medical comorbidities,
and psychosocial stressors.11,12 Although there are no disease-specific pain assess-
ment tools for patients with heart failure, using the Edmonton Symptom Assessment
Scale is a simple standardized way to assess and monitor pain.13 The Memorial Symp-
tom Assessment Scale can also be used and provides clinicians with a measurement
of pain and a multitude of other symptoms.14
Etiology of Pain
Chronic kidney disease–mineral and bone disorder
Patients with ESRD on hemodialysis will have some degree of chronic kidney disease–
mineral and bone disorder (CKD-MBD), a disorder marked by abnormalities in bone
4 Phongtankuel et al
Calciphylaxis
Calciphylaxis is a rare, painful disorder that deserves mention, as it carries significant
risk of morbidity and mortality. This condition results from abnormal metabolism of
calcium and phosphate, leading to arteriole calcification and painful skin lesions
caused by vascular ischemia and necrosis.27 Patients will experience intense, excru-
ciating pain that is challenging for providers to manage.
Polycystic kidney disease
Patients with ESRD caused by polycystic kidney disease (PCKD) often experience
abdominal, back, and flank pain that is thought to be caused by cyst involvement.
Cyst enlargement can stretch the kidney capsule resulting in pain, which is typically
dull in nature.28 Diagnosis can be difficult given that pain can present in various re-
gions of the abdomen and can mimic other gastrointestinal or musculoskeletal condi-
tions. Prevalence of pain occurs in more than 60% of PCKD patients.29
STROKE
Epidemiology and Prevalence
Stroke affects almost 800,000 people annually in the United States and is a leading
cause of long-term disability.44 In addition to well-recognized impairments in motor
6 Phongtankuel et al
function, cognition, and language, stroke can also result in pain that is difficult to diag-
nosis and treat.
Poststroke pain (PSP) affects more than half of all stroke patients and results in
decreased function and quality of life.45 Pain may be broadly categorized as either
neurologic or musculoskeletal in origin. Because of differences in definition and iden-
tification, the reported prevalence of PSP varies, ranging from 4% to 66%.46,47 Com-
mon types of PSP encountered include central poststroke pain (CPSP), muscle
spasticity, and poststroke shoulder pain.47,48
Etiology of Pain
Central poststroke pain
CPSP is a type of central neuropathic pain typically characterized by dysesthestic and
allodynic qualities on the side contralateral to the stroke.49 Although CPSP affects up
to one-third of stroke patients, its insidious onset and subacute natural history compli-
cate diagnosis, as CPSP usually does not present until at least a month after stroke
onset.50,51 Most cases present within a year.52 The pain of CPSP can be especially se-
vere and intractable, posing a significant therapeutic challenge.51
Muscle spasticity
Muscle spasticity–related pain is another common source of chronic pain experienced
by stroke patients and develops in nearly 25% of patients within 1 week of stroke.53
Most stroke patients with spasticity will go on to have pain in the affected limb(s).53
Although a clear mechanism by which spasticity results in pain has not been identified,
it is hypothesized that abnormal tensile load on muscles and ligaments leads to noci-
ceptive pain.54
In addition, PSP patients often have multiple medical comorbidities that frequently
complicate both the diagnosis and management of pain. Polypharmacy and adverse
side effects of analgesic medications in this population can threaten cognition and
arousal and limit pharmacologic treatment options.
Management of PSP typically involves a focus on both central and peripheral tar-
gets. Depending on the subtype of PSP, interventions aim to address peripheral
inflammation, relay of nociceptive input at the spinal cord, central maladaptive neuro-
plasticity, or mood impairments. Although several classes of medications have shown
efficacy in treating PSP, many of these medications have adverse side effects on
mental status and cognition. Therefore, it is crucial to regularly assess whether the
medication is still necessary for pain control and is continuing to provide benefit to
the patient.
For CPSP, pharmacologic therapies fall broadly into several categories: aminergic
agents, calcium channel blockers, GABAergic agents, glutamate antagonists, and
membrane stabilizers. Amitriptyline and lamotrigine are considered first-line treat-
ments for CPSP, although adverse anticholinergic side effects frequently limit use.59
Mexiletine, fluvoxamine, and gabapentin have been used as second-line drugs. Pa-
tients who are refractory to pharmacotherapy may benefit from referral to pain man-
agement specialists for neuromodulatory interventions, which include transcranial or
deep brain stimulatory technologies.
Treatment options for spasticity run the spectrum from nonpharmacologic strate-
gies to pharmacologic and interventional approaches.60 Stretching, splinting, and
strengthening of antagonist muscles by trained physical and occupational therapists
form an important cornerstone of spasticity treatment. Oral medications, such as bac-
lofen, tizanidine, diazepam, and dantrolene, may facilitate the effect of stretching and
other therapies. Because sedation is a common side effect for many of these medica-
tions, generally accepted practice is to start at the lowest dose before bed and then
titrating up in dose and frequency. For focal spasticity, focal injections of phenol or
botulinum toxin have shown efficacy in reducing tone and improving function.
In the immediate poststroke period, the combination of muscle flaccidity and joint
laxity combine to produce a window of increased vulnerability to injury. Thus, a pre-
ventive approach to joint injury in conjunction with early physical/occupational ther-
apy, as well as appropriate mechanical support and mobility control, may reduce
the incidence of poststroke shoulder pain.61 Medications used for poststroke shoulder
pain center around the control of inflammation, with NSAIDs often used first.61 Topical
analgesic medications in the form of creams (ie, lidocaine, capsaicin), gels (ie, diclo-
fenac, ketoprofen, ibuprofen), or patches (ie, lidocaine, diclofenac) may be used to
provide targeted pain relief. To the degree that muscle spasticity contributes to
pain, antispasmodic agents such as baclofen may also be useful. Transcutaneous
neuromuscular electrical stimulation and functional electrical stimulation may also
be used to improve pain, range of motion, and arm function.62 If focal pathology at
one of the many joints comprising the shoulder is suspected, targeted delivery of com-
bined anesthetic and corticosteroid may be used for both immediate pain relief and
longer-term inflammatory control. For refractory cases of shoulder pain in which per-
manent mechanical contracture or defect is suspected, surgery may represent defin-
itive treatment to release contracted shoulder muscles or rotator cuff tears.
SUMMARY
ACKNOWLEDGMENTS
The authors acknowledge the significant contribution of Shawn Paustian who assis-
ted in the literature review and writing of the article.
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