BJA Advance Access published online on May 16, 2008
British Journal of Anaesthesia, doi:10.1093/bja/aen090
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Advances in understanding the mechanisms and management of persistent pain in older adults 
1 Department of Psychiatry
2 Department of Anesthesiology
3 Department of Medicine, University of Pittsburg School of Medicine
4 Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, USA
5 Department of Medicine at Northwestern University School of Medicine, USA
* Corresponding author. E-mail: weinerdk{at}upmc.edu
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 ageing-associated 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 non-malignant 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.
Keywords: age factors; pain; chronic; stress
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-translational.asp.
Declaration of interest. Dr Karp is an advisor for Eli Lily and Myriad Pharmaceuticals. He also received medication supplies for an investigator-initiated trial from Eli Lily and is a stockholder of Corcept.
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