How to best treat the elderly and frail patients suffering from neuropathic pain? For painphysicians this is a key question. Happily new data are guiding our prescribing behaviour in this field. The most important issue is how to achieve optimal analgesic efficacy without creating bothersome side effects like dizziness and unsteadiness or unwanted drug interactons! For instance, the best analgesics, the TCAs in elderly can cause cognitive functiondisturbances, confusion, gait disturbances, and falls. 

Elderly and frail patients suffering from neuropathic pain: increasing 

In the western world more than 50 million individuals are 65 years or older and most probably more than 18 million of these individuals are 80 years or older. Only in Germany and Italy in 2008 more than 28 million people were 65 years or older. This population of older people are at high risk to suffer from neuropathic pain due to the fact that the various causes of neuropathic pain such as diabetes and herpes zoster increase in incidence with age.

Treatment of these patients is not an easy task, as most patient suffer from more than one disease and are treated with various drugs. Interactions and side effects very often limit the use of drugs normally prescribed in younger patients.

In a recent review from Dukes university this issue is covered in great extent.  

The authors are focussing their discussion on 5 important topics: 

1. the complexity of treatment decisions in older patients due to aged heterogeneity,
2. multimorbidity, and polypharmacy,
3. selection of treatment in an effort to maximize patients' functional abilities in addition to relieving their pain,
4. careful dosing (usually lower) and monitoring of pharmacotherapy relative to younger patients due to age-related changes in pharmacokinetics and pharmacodynamics, and
5. the underrepresentation of older adults in clinical trials of neuropathic pain treatments, which further compromises physicians' ability to make informed treatment decisions. ^[1]

In our clinic we continously search for new and better drugs and treatments for patients suffering from neuropathic pain. As many patients suffering from neuropathic pain are elderly people, with co-morbidity, often also facing cardiovascular problems, drugs like amitriptyline are relative contraindicated. Moreover, the sedative side effects are a big problem for these frail and mostly gait-unstable patients with polyneuropathy. Pain in the elderly is distinctly different from pain experienced by younger individuals.  ^[5] And thus pain in elderly needs individualized treatment. Considering side effect profiles is an important aspect of such a treatment.

Example of analgesic treatments with a low side effect profile are palmitoylethalonamide (PEA)^[6][7][8][9] and alpha-lipoic acid.^[10][11][12] Especially the absence of sedative side effects is important.

In relation to the first molecule, PEA, many elderly patients have been treated without side effect or dose limiting problems, or interaction problems. Within the context of clinical studies more then 350 elderly patients have been treated with palmitoylethanolamide without side effect problems, and also in our hands, we did not detect any clinical relevant side effects, even not in a patient aged 90.

To date the following numbers of elderly patients treated with palmitoylethanolamide (Normast) have been evaluated: - 111 between 65 and 70 years old- 116 between 71 and 75 y.o.- 63 between 76 and 80 y.o.- 45 between 81 and 85 y.o.- 20 between 86 and 90 y.o. (Epitech data on file, december 2010)

To use our own body pain-defense system molecules in treating neuropathic pain (gliopathic pain) seems a new important and clever inroad in the treatment of such debilitating painstates as neuropathic pain. The fact that these body-own fatty acids are devoid of sedative side effects in the elderly is an important aspect in treating these patients.

In the following Youtube patient demonstration an elderly retired physician describes his experience with treatment of pregabaline and palmitoylethanolamide. He especially adresses the troublesome sedative side effects, like dizziness in pregabaline and the absence of such side effects in palmitoylethanolamide.

On www.drugs.com the following % of side effects of pregabaline are mentioned:

Nervous system side effects including dizziness (up to 38%), somnolence (up to 28%), ataxia (up to 20%), tremor (up to 11%), neuropathy (up to 9%), abnormal thinking (up to 9%), abnormal gait (up to 5%), confusion (up to 7%), speech disorder (up to 7%), amnesia (up to 6%), incoordination (up to 6%), twitching (up to 5%), vertigo (up to 4%), myoclonus (up to 4%), euphoria (up to 3%), and nervousness (up to 1%) have been reported.  

Our physician suffering from acure severe sciatic pain treated by his neurologist with pregabaline reported to be unable to tell what day it was, and felt very dizzy. These side effects disappeared quickly after stopping the pregabline and starting the palmitoylethanolamide. 

November 2010, Jan M. Keppel Hesselink, MD, PhD 

Treatment considerations for elderly and frail patients with neuropathic pain 

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