Case of the Month #42: Persistent Pain in Older Adults by Dr Sonia Pierce

Mrs D was assessed by the pain service’s multidisciplinary team. This was a joint initial assessment with a Consultant in Pain Medicine and a Specialist Occupational Therapist. She told them her story of pain, explaining that she had suffered with severe low back pain and aching joint pain for many years but was now struggling to cope.

She recalled having back pain in her early 30s, following the birth of her three children. She carried on despite her pain for years and once her children were old enough, she returned to her role as a part time shop assistant in her local grocer shop. This job often involved carrying heavy boxes and she remembered having back ache most days from then on, which she attributed to lifting. Her pain was a little easier to manage when she reached retirement age, and she recalls enjoying frequent travels with her husband. She had an episode of excruciating back pain when caring for one of her grandsons when she was 65, associated with carrying him in the park. Over the past 15 years, she has noticed more and more joint aches and pains and underwent a right total hip replacement for severe osteoarthritis when she was 73. Now she complained of pain affecting her hands, shoulders, neck, low back, hips, knees and feet. She often also felt an aching discomfort in her muscles throughout her body. Her pain was generally worse in the afternoon and evening and after activity.

She was unable to do many of the activities she enjoyed such as gardening, knitting and going out for lunch with her friends. Since her husband died 5 years earlier, she had lost contact with many of her couple friends and generally stayed indoors. She stumbled in her garden last year and was fearful of going out to the shops. She was reliant on weekly visits from her son to do the shopping and any heavier jobs that needed doing around the house. Despite her pain, she tried to keep busy in the morning doing housework and gardening until a task was done. She was exhausted by the early afternoon. She was unable to sleep well because of her pain and found it difficult to concentrate on reading, doing crosswords or writing letters. She had tried numerous medications over the years but found they either did not help, made her sleepy or constipated. She took up four Co-Codamol 30/500 tablets a day, typically two tablets most mornings to get going and occasionally as needed in the afternoon to allow her to get tasks done. She was on several other medications including antihypertensives, aspirin and levothyroxine.

• What are the other factors in her social history you would like to know?
• How would you assess and manage her risk of falls?
• What would you consider when formulating a management plan with Mrs D?