- Lower back pain has a high prevalence in older persons.
The prevalence ranges between 21% and 75%. This leads to a huge burden with functional disability in 60% of these individuals leading to diminished quality of life [1, 2]. Despite its high prevalence, low back pain is not an inherent part of the aging process. It is related to the increased burden of pathology, lifestyles, genetics, and physiologic factors thus highlighting the fact that phenotypical age can be a more helpful maker of prognosis .
- Most back pain is due to common causes.
Though the common causes of lower back pain range from structural changes and deformities due to osteoarthritis of the joints, disc related changes, vertebral body changes, sarcopenia and secondary neural compression, it will be important to exclude the red flags – particularly when there is a new onset pain or change in the intensity of site of pain .
- Red flags of back pain.
Assess for red flags of back pain to exclude fractures (0.7% to 4%), malignancy (0.3% to 3.8%), infections (0.1% to 0.8%) and to a lesser degree autoimmune inflammatory condition such as spondyloarthropathy or polymyalgia rheumatica. Osteoporotic fractures are commonly misdiagnosed with acute low back pain and can happen without falls or injuries . Most red flag conditions can be excluded on careful history and examination. Imaging should be reserved for red flag conditions, or where it may alter management.
- Assess beyond the back.
A Comprehensive Geriatric Assessment along with multidimensional pain assessment tools and non-verbal tools for pain assessment and its interference on daily function, sleep, mood, coping styles, beliefs and support system are important [6, 7, 8]. A multidisciplinary team can be helpful in all aspects of person centred care .
- Consider the age-related conditions.
Common age-related conditions play a contributory role in their predicament and management – frailty, polypharmacy, cognitive dysfunction, falls, and concurrent medical comorbidities .
- Review the role of medications.
Medications need to be tailored to the pharmacokinetic and pharmacodynamic changes in the older person such as reduced bioavailability, altered renal and hepatic function affecting clearance, altered drug distribution and increased sensitivity to analgesia [11, 12].
- Opioids—beware of the risks.
Long-term use of opioids has limited evidence of efficacy and has established risks such as nausea, constipation, cognitive impairment and increased falls. Carefully weigh the benefits and negative consequences of pain prior to initiating a trial of opioids. Start slow, taper dose to lowest effective dose and discontinue if treatment goals are not met .
- Active physical therapies are a key treatment, irrespective of age.
Physical therapies tailored to the individual to increase daily physical activity, exercises to enhance strength, maintain range of motions and tolerances, walking, hydrotherapy, yoga and Tai-Chi are beneficial for chronic pain. In addition, physical therapies have benefits for general health, emotional wellbeing and other co-morbid medical conditions such as diabetes, cardiorespiratory diseases, and osteoporosis. Exercises need to be tailored to an individual’s preference and medical conditions [14, 15].
- Psychosocial factors
Addressing the psychosocial factors of ageing is important as they are bidirectional both as a contributor and a consequence of persistent pain. These factors include mood dysfunctions – depression and anxiety, loss of family members and friends, social isolation (which has increased markedly due to COVID-19 pandemic) and loss of independence, limited access and resources to care. The Comprehensive Geriatric Assessment approach focuses on maintaining social and recreational engagement and maintaining functional independence and avoiding unnecessary residential care admission. Unrelieved pain can adversely affect each of these important activities, as can adverse treatment effects [8, 16, 17].
- Age and cognition are not insurmountable barriers to psychological therapies.
Cognitive behavioural therapies to address expectations, activity pacing, relaxation, improving sleep hygiene, addressing unhelpful beliefs and behaviours are helpful with significant functional benefits, improved coping skills and quality of life . Spousal participation and behavioural strategies can be more helpful with severe cognitive impairment.
de Souza IMB, Sakaguchi TF, Yuan SLK, et al. Prevalence of low back pain in the elderly population: a systematic review. Clinics (Sao Paulo). 2019;74:e789. Published 2019 Oct 28. doi:10.6061/clinics/2019/e789
 Makris UE, Abrams RC, Gurland B, Reid MC. Management of persistent pain in the older patient: a clinical review. JAMA. 2014;312(8):825-836. doi:10.1001/jama.2014.9405
 Liu Z, Kuo PL, Horvath S, Crimmins E, Ferrucci L, Levine M. A new aging measure captures morbidity and mortality risk across diverse subpopulations from NHANES IV: A cohort study [published correction appears in PLoS Med. 2019 Feb 25;16(2):e1002760]. PLoS Med. 2018;15(12):e1002718. Published 2018 Dec 31. doi:10.1371/journal.pmed.1002718
 Wong AY, Karppinen J, Samartzis D. Low back pain in older adults: risk factors, management options and future directions. Scoliosis Spinal Disord. 2017;12:14. Published 2017 Apr 18. doi:10.1186/s13013-017-0121-3
 Pain 2018: Refresher Courses, 17th World Congress on Pain. Ebooks.iasp-pain.org. https://ebooks.iasp-pain.org/pain_2018_refresher_courses. Published 2020. Accessed November 15, 2020. p 85-96
 Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet. 1993;342(8878):1032-1036. doi:10.1016/0140-6736(93)92884-v
 Devons CA. Comprehensive geriatric assessment: making the most of the aging years. Curr Opin Clin Nutr Metab Care. 2002;5(1):19-24. doi:10.1097/00075197-200201000-00004
 Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017;9(9):CD006211. Published 2017 Sep 12. doi:10.1002/14651858.CD006211.pub3
 Hadjistavropoulos T, Herr K, Turk DC, et al. An interdisciplinary expert consensus statement on assessment of pain in older persons. Clin J Pain. 2007;23(1 Suppl):S1-S43. doi:10.1097/AJP.0b013e31802be869
 Schug SA, Palmer GM, Scott DA, Alcock M, Halliwell R, Mott JF; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2020), Acute Pain Management: Scientific Evidence (5th edition), ANZCA & FPM, Melbourne. P 753-767
 AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(6 Suppl):S205-S224. doi:10.1046/j.1532-5415.50.6s.1.x
 Reid MC, Eccleston C, Pillemer K. Management of chronic pain in older adults. BMJ. 2015;350:h532. Published 2015 Feb 13. doi:10.1136/bmj.h532
 Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162(4):276-286. doi:10.7326/M14-2559
 Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;4(4):CD011279. Published 2017 Apr 24. doi:10.1002/14651858.CD011279.pub3
[15 Vadalà G, Russo F, De Salvatore S, et al. Physical Activity for the Treatment of Chronic Low Back Pain in Elderly Patients: A Systematic Review. J Clin Med. 2020;9(4):1023. Published 2020 Apr 5. doi:10.3390/jcm9041023
 Fancourt, D., & Steptoe, A. (2018). Physical and Psychosocial Factors in the Prevention of Chronic Pain in Older Age. The journal of pain, 19(12), 1385–1391. https://doi.org/10.1016/j.jpain.2018.06.001
 Pain 2018: Refresher Courses, 17th World Congress on Pain. Ebooks.iasp-pain.org. https://ebooks.iasp-pain.org/pain_2018_refresher_courses. Published 2020. Accessed November 15, 2020. p 53 -65
Dr. Raj Anand, MBBS, FRACP, FFPMANZCA
Consultant Pain Physician and Rheumatologist,
Royal Rehab Hospital, St. Vincent’s Hospital and Prince of Wales Private Hospital, Sydney, Australia.
Assoc. Prof Benny Katz. FRACP FFPMANZCA. Department of Geriatric Medicine, St Vincent’s Hospital Melbourne.
No financial disclosures to declare.
Dr. David Lussier
Faculty of Medicine and Health Sciences, Division of Geriatric Medicine
Montreal, QC, Canada
Cary Reid, PhD, MD
Weill Cornell Medicine, Geriatrics & Palliative Medicine
Cornell University; New York-Presbyterian Hospital
New York, NY, United States