Chronic diffuse musculoskeletal pain in the elderly

Specialty: Geriatrics.

• generalized osteoarticular pain
• diffuse senile pain
• persistent musculoskeletal pain in the elderly
• chronic senile pain syndrome

Why it occurs

• Severe multicentric osteoarthritis with simultaneous involvement of the knees, hips, spine and hands
• Lumbar canal stenosis of degenerative origin associated with bilateral neurogenic claudication
• Senile osteomalacia secondary to a profound and prolonged deficiency of Vitamin D
• Polymyalgia rheumatica of late onset with characteristic involvement of the shoulder and pelvic girdles
• Myopathy of metabolic or inflammatory origin (severe hypothyroidism, statin-induced myopathy)

Initial workup

Blood analysis with determination of erythrocyte sedimentation rate (ESR), ultrasensitive C-reactive protein (CRP), rheumatoid factor, anti-cyclic citrullinated peptide antibodies (APCC), alkaline phosphatase of bone origin, calcium, phosphorus, 25-hydroxyvitamin D and thyroid hormones (TSH, free T4); plain x-rays of the lumbosacral spine, both knees and pelvis; bone densitometry (DEXA); shoulder ultrasound if there is suspicion of polymyalgia rheumatica (search for bilateral subdeltoid bursitis).

Standard management

• Paracetamol — 500 mg to 1 g orally every 8 hours on a strictly scheduled basis, not on demand, to maintain stable serum levels and reduce the consumption of more powerful analgesics
• Prednisone — 10 mg to 15 mg orally daily in the morning if a diagnosis of polymyalgia rheumatica is confirmed, reducing the dose very gradually over months under monitoring of acute phase reactants
• Duloxetine — 30 mg orally daily in the morning, useful as an adjuvant in chronic osteoarticular and neuropathic pain, monitoring the appearance of hyponatremia due to SIADH
• Avoid the chronic use of NSAIDs (ibuprofen, diclofenac, naproxen) due to their high renal, gastrointestinal and cardiovascular toxicity in the elderly.