Management strategies for the treatment of neuropathic pain in the elderly

Pain caused by dysfunction or damage to the peripheral or central nervous system is typified by the symptoms described by patients with painful diabetic neuropathy, post-herpetic neuralgia and central poststroke pain. All these conditions are more common in the elderly. Neuropathic pain has long been recognised as one of the more difficult types of pain to treat; however, with the current emphasis on providing a multidisciplinary assessment and approach to management, more patients will be offered relief of their symptoms and an improved quality of life. Despite the use of combination drug therapy, adequate pain relief in the elderly is difficult to achieve without adverse effects. In an attempt to minimise these it is important to include non-drug treatment options in the management plan. Lifestyle changes and environmental modification, together with encouragement to adopt an appropriate exercise programme and an emphasis on maintaining mobility and independence should always be considered. Interventional therapy ranging from simple nerve blocks to intrathecal drug delivery can be of value. Drug treatment remains the mainstay of therapy. Tricyclic antidepressants such as amitriptyline, while having significant adverse effects in the elderly, have a number needed to treat (NNT) of 3.5 for 50% pain relief in diabetic neuropathy and 2.1 for 50% pain relief in postherpetic neuralgia. The newer antiepileptic drugs, such as gabapentin, appear to have a better adverse effect profile and provide similar efficacy with the NNT for treating painful diabetic neuropathy being 3.7 and 3.2 for treating pain in postherpetic neuralgia. As our understanding of the complexities of the pain processes increases, we are becoming more able to appropriately combine treatments to achieve not only improved pain relief but also improved function.