Chronic pain in elderly and geriatric patients: clinical guidelines

List of Abbreviations

BP – blood pressure

ALT – alanine aminotransferase

AST - aspartate aminotransferase

DDS – dietary supplement

VAS – visual analog scale

HIV – human immunodeficiency virus

GS – geriatric syndrome

mGS – microcrystalline glucosamine sulfate

HRT – hormone replacement therapy

GI – gastrointestinal tract

CHD – coronary heart disease

PPI – proton pump inhibitors

CGA – comprehensive geriatric assessment

CT – computed tomography

MSM – methylsulfonylmethane

MRI – magnetic resonance imaging

NP – neuropathic pain

NSAIDs – non-steroidal anti-inflammatory drugs

OA – osteoarthritis

ACS acute coronary syndrome

RCTs – Randomized Controlled Trials

FS – frailty syndrome

GFR – glomerular filtration rate

ESR – erythrocyte sedimentation rate

COPD – chronic obstructive pulmonary disease

CS – chondroitin sulfate

CNS – central nervous system

COX – cyclooxygenase

ENMG – electroneuromyography

25(OH)D – 25-hydroxyvitamin D

DN4 - Douleur Neuropathique 4

FPS – Faces Pain Scale

MMSE – Mini-Mental State Examination

NRS – Numeric Rating Scale for pain

PAINAD – Pain Assessment in Advanced Dementia Scale

START – Screening Tool to Alert to Right Treatment

STOPP – Screening Tool of Older Persons' Prescriptions

Terms and Definitions

Autonomy – independence from outside assistance and the ability to make decisions independently.

Basic functional activity – a person's ability to independently perform basic activities of daily living (personal hygiene, eating, dressing, bathing, using the toilet, short-distance transfers, climbing stairs, controlling urination and defecation).

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Geriatric syndrome - a multifactorial age-associated clinical condition that impairs quality of life, increases the risk of adverse outcomes (death, dependence on outside assistance, readmissions, need for long-term care) and functional decline. Unlike a traditional clinical syndrome, a geriatric syndrome is not a manifestation of pathology in a single organ or body system, but reflects a complex of changes across multiple systems. The onset of one geriatric syndrome increases the risk of developing others.

Instrumental functional activity – a person's ability to independently perform activities of daily living that are more complex than basic functional activities (using the telephone, shopping, cooking, housework, using transport, doing laundry, cleaning, taking medications, managing finances).

Comprehensive geriatric assessment – a multidimensional interdisciplinary diagnostic process that includes assessing physical and psychoemotional status, functional capabilities, and identifying social problems in an older person in order to develop a treatment and monitoring plan aimed at restoring or maintaining the patient's level of functional activity.

Nociceptive pain – occurs when a tissue-damaging stimulus acts on peripheral pain receptors. The causes of this pain can be various traumatic, infectious, dysmetabolic, and other injuries (carcinomatosis, metastases, retroperitoneal neoplasms) that cause the activation of peripheral pain receptors. Nociceptive pain is most often acute pain with all its inherent characteristics.

Neuropathic pain – is pain caused by a lesion or disease of the somatosensory system. Damage to the central or peripheral somatosensory system is the source of central or peripheral neuropathic pain, respectively.

Pre-frailty - a state preceding the development of frailty syndrome, characterized by the presence of individual signs of frailty that are quantitatively insufficient to diagnose frailty.

Polypharmacy – simultaneous prescription of 5 or more drug items to a patient, or over 10 items during a course of treatment.

Polymorbidity (multimorbidity) - the presence of two or more chronic diseases in a single patient, regardless of the activity of each.

Sarcopenia – a geriatric syndrome characterized by age-associated progressive generalized loss of skeletal muscle mass and strength, which is associated with an increased likelihood of adverse outcomes, including falls, fractures, physical disability, and mortality

Frailty – a geriatric syndrome characterized by an age-associated decline in the physiological reserve and function of multiple body systems, leading to increased vulnerability of the older person to endo- and exogenous factors and a high risk of adverse health outcomes, loss of autonomy, and death. Frailty is closely associated with other geriatric syndromes and multimorbidity, is potentially reversible, and influences patient management tactics. There are two models describing frailty, namely the phenotypic model, which includes five criteria (unintentional weight loss, low grip strength, self-reported exhaustion, slow walking speed, and low physical activity), and the deficit accumulation model, which involves assessing 40 to 70 deficits and calculating the frailty index.

Physical activity - any bodily movement produced by skeletal muscles that requires energy expenditure.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Chronic pain – an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage, persisting for 3 months or more [1].

Understanding and assessing the physiological changes occurring in elderly individuals with chronic pain can potentially lead to better therapeutic outcomes and patient satisfaction in the geriatric population.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Most frequent causes of chronic pain in patients over 60 years of age

• Cardiovascular system – coronary artery disease, peripheral artery disease
• Connective tissue diseases – osteoarthritis, rheumatoid arthritis, gout and pseudogout, polymyalgia rheumatica, spinal stenosis, lower back pain, myofascial syndrome, osteoporosis, bursitis, tendinitis
• Oncological diseases
• Chemotherapy-induced neuropathic pain
• Nervous system – headache, peripheral neuropathy, entrapment neuropathy, radiculopathy, Parkinson's disease, post-stroke pain
• Depression
• Gastrointestinal tract – constipation, diverticulitis, irritable bowel syndrome, gallbladder disease
• Respiratory system – COPD, pleurisy
• Endocrine system – diabetic neuropathy, Paget's disease
• Urinary system – chronic cystitis
• Infectious diseases – herpes zoster, postherpetic neuralgia, HIV-associated neuropathy
• Depression
• Skin pathology – pressure or ischemic ulcers, burns, scleroderma

Chronic pain is a complex pathogenetic condition that includes changes in the pain sensitivity regulation system and the formation of an individual psychological response to pain sensations, shaping the patient's own attitude toward the emerged problem [2].

The pathogenesis of chronic pain is heterogeneous and includes the activation of the nociceptive system and neuropathic damage, colored by the patient's psychogenic response, depending on a number of comorbid and social factors [3]. Tissue damage leads to the activation of nociceptors, and the resulting pain is called nociceptive. Primary hyperalgesia develops in the area of tissue damage, while the zone of secondary hyperalgesia can spread to adjacent undamaged areas. The development of primary hyperalgesia is based on the phenomenon of nociceptor sensitization — an increase in their sensitivity to mechanical and thermal stimuli [4]. This peripheral sensitization occurs as a result of the action of biologically active molecules with pro-inflammatory and algogenic effects (prostaglandins, cytokines, biogenic amines, neurokinins, glutamate, nerve growth factor, etc.), which are released from damaged tissue, mast cells, enter from blood plasma, and are secreted from peripheral terminals of unmyelinated nerve fibers. Neuropeptides (substance P, neurokinin A, etc.), released during the activation of nociceptive C-fibers, lead to the development of neurogenic inflammation, causing local vasodilation and increased vascular wall permeability. The released chemical compounds, through interaction with corresponding receptors on nociceptive afferent terminals, trigger a cascade of biochemical reactions that make the nerve fiber more excitable and more sensitive to external stimuli [5].

The severity and duration of peripheral and central sensitization in acute nociceptive pain directly depend on the nature and duration of tissue damage. During normal tissue healing, the phenomenon of peripheral and central sensitization should also disappear. However, under conditions of altered organism reactivity, peripheral and central sensitization may persist even after tissue healing, thereby contributing to the chronification of pain. To a large extent, this may be due to the inefficiency of descending inhibitory control [2].

Damage to the peripheral nervous system or central parts of the somatosensory apparatus leads to neuropathic pain. The most frequent causes are pathology of the peripheral nervous system (peripheral neuropathies of various etiologies, e.g., diabetic) or damage to CNS structures (spinal cord and brain injuries, strokes, multiple sclerosis, syringomyelia, Parkinson's disease, etc.).

The pathophysiological basis of neuropathic pain is disorders in the mechanisms of generation and conduction of nociceptive signals in nerve fibers and the processes controlling the excitability of nociceptive neurons in the structures of the spinal cord and brain. Nerve damage leads to structural and functional alterations in the nerve fiber [4].

Chronic pain syndrome in older age groups has a number of pathogenetic features associated both with aging itself (processes of systemic inflammation that increase the number of pro-inflammatory mediators and algogens [6, 7]) and with the presence of other geriatric syndromes: sarcopenia (a muscle with impaired catabolism and anabolism processes synthesizes a large amount of COX-2, which affects pain intensification) [8]; anxiety and depression; osteoporosis; dehydration, and malnutrition.

The pathogenetic mechanisms of chronic pain are driven by physiological changes in the elderly: a decrease in the number of neurotransmitters (gamma-aminobutyric acid, serotonin, norepinephrine, and acetylcholine), a decrease in the number of peripheral nociceptive neurons, an increase in the pain threshold, and a decrease in the synthesis of endogenous opioids. In addition, the cause of pain is homeostenosis during aging, which consists in the loss of the homeostatic reserve of various organ systems, manifested as a decrease in liver and kidney function, a decrease in muscle mass, leading to an increased risk of falls, decreased appetite, sleep disorders, depression, geriatric delirium, agitation, and overall, to the aggravation of frailty [9].

1.3 Epidemiology of the Disease or Condition

The prevalence of chronic pain in older age groups ranges from 27% to 86%, depending on the population characteristics of the patients included in the analysis [10, 11, 12].

Data on the prevalence of chronic pain in patients over 60 years of age in the Russian Federation are absent.

Older age groups are characterized by a long duration of chronic pain, ranging according to various estimates from 3–6 to 25–30 years [13, 14, 15].

According to pathogenetic origin, musculoskeletal pain (40%) and peripheral neuropathic pain (40%) are most common, among which lower back or neck pain (65%) and chronic joint pain (20%) occur most frequently [16].

Osteoarthritis is a particular problem, the prevalence of which increases with patient aging; according to various data, 30–50% of the population over 65 years of age have clinical symptoms of OA [17, 18]. Radiological symptoms of OA (osteophytes, joint space narrowing, subchondral osteosclerosis) are detected in more than 80% of examined patients over 60 years of age in at least one joint [19]. It is worth noting that not all patients with joint pain have radiological signs of OA. Thus, in a study of 480 patients over 65 years of age with joint pain, only 50% had radiological confirmation of OA [20].

1.4 Features of Coding the Disease or Condition

R52.1 – constant intractable pain;

R52.2 – other constant pain;

R52.9 – pain, unspecified;

M25.5 – pain in joint;

M54.5 – low back pain;

M54. – dorsalgia;

R10.2 – pelvic and perineal pain.

1.5 Classification of the disease or condition

In clinical practice, several classifications of pain syndrome are used depending on etiology (oncological, non-oncological, musculoskeletal), pathophysiology (nociceptive, neuropathic, psychogenic), anatomical localization (back pain, joint pain, headache, leg pain, etc.), temporal factor (persistent, constant), and pain intensity (mild, moderate, severe). However, as a rule, only the pathophysiological classification and degree of intensity influence the choice of medical interventions. Nevertheless, the very concept of chronic pain implies a multicomponent pathophysiological structure.

There is no universally accepted clinical classification of chronic pain, as this has no clinical or strategic significance. It is sufficient to characterize the causes and risk factors for the persistence and intensification of pain syndrome [21, 22, 23].

1.6 Clinical presentation of the disease or condition

Elderly and senile patients do not always report the presence of pain syndrome. Older adults may underestimate pain severity due to misconceptions that pain is a normal part of aging, a tendency toward stoicism [24], or fear of dependency [25]. Patients with dementia (moderate or severe) often do not report pain sensations at all [26].

Clinical characteristics of pain may be understated because some older patients mistakenly believe pain is a normal process of aging [27]. These circumstances require targeted questioning of patients regarding the presence of pain syndrome.

Older age groups report higher pain intensity compared to younger patients [28].

It should be remembered that the presence of chronic pain is always associated with a decline in function. Thus, musculoskeletal pain (back pain, joint pain) leads to dysfunctions of the joints and/or spine, which in turn reduces patients' activity and mobility and leads to increased dependency in daily life. Headache always leads to a range of anxiety and depressive disorders, which ultimately increase the degree of cognitive impairment in patients [29].

Chronic pain in older age groups always has an adverse impact on quality of life [30, 31, 32], physical and mental status of patients [33], mood, ability to work, and participation in social life [34]. Decreased activity is the very risk factor that modulates increased mortality in patients with chronic pain [35].

Chronic pain accompanied by a decrease in the physical and functional activity of patients is an independent risk factor for the development of depression [34], which is why these conditions frequently co-occur in routine clinical practice.

Sympathoadrenal reactions occurring in response to pain sensations can lead to a range of organ and systemic changes that may act either as primary causes of pathologies or as factors aggravating comorbid conditions in older adults (Table 1) [36].

Table 1. Organ and systemic changes in pain syndrome

A decrease in daily physical activity (due to pain and functional impairment) increases the decompensation of polymorbid conditions, as it prevents full-scale rehabilitation measures and worsens congestion in cardiovascular diseases.

The presence of chronic pain in patients over 60 years of age leads to the development or exacerbation of a range of geriatric syndromes [37-57]; on average, patients with chronic pain present with 4 to 6 syndromes. These include:

1. Senile asthenia
2. Sleep disorders
3. Cognitive impairment
4. Anxiety and depressive disorders
5. Dizziness
6. Falls
7. Constipation
8. Sarcopenia
9. Decreased mobility
10. Malnutrition

The most frequent localizations of chronic pain syndrome in patients over 60 years of age are the joints, lower back, and cervical spine [58, 59, 60]. Neuropathic pain is detected in 10 – 52% of patients over 60 [61 - 65].

It should be noted that osteoarthritis and frailty, both individually and combined, increase the risk of gait disorders, falls, fractures, sarcopenia, and chronic pain, which significantly impacts the prognosis of life expectancy and quality of life in older age groups [66, 67].

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnostic criterion for chronic pain in patients over 60 years of age is the presence of a persistent pain syndrome lasting for 3 months or more.

The perception of pain and individual characteristics of pain syndrome are always a subjective assessment, which is reflected in the international definition of the term "pain" [1]. Therefore, there is no single objective (instrumental or laboratory) method to measure the sensation of pain. Scales that allow for the objectification of pain syndrome are most commonly used.

2.1 Complaints and Anamnesis

Comments: since chronic pain is a very widespread problem among the population over 60 years of age [69 - 74], and its presence is associated with a significant decrease in quality of life, an increase in disability rates, social isolation, and higher healthcare costs [34, 75, 76, 77], screening and early initiation of interventions can improve patients' functional status and determine their needs for outside assistance and care. Furthermore, chronic pain increases all-cause mortality by 57% in the population over 60 years of age [35].

Comments: assessment of pain intensity determines the scope of pharmacotherapy interventions and the need for outside assistance, and allows monitoring of the efficacy of recommended interventions. Pain assessment is performed by a physician or nurse during each visit and patient examination, both separately during movement and at rest, which must be documented in medical records [79].

Comments: The identification of frailty syndrome determines the prognosis for the health and life of an older patient, management tactics, and the need for outside assistance and care. Screening for frailty at the primary care level has proven effective in preventing the decline of functional status in elderly and senile patients. When patients aged 60 and older seek medical care, signs indicating the possible presence of frailty syndrome or an increased risk of its development should be actively identified. The use of short, country-validated questionnaires aimed at identifying the main signs of frailty and key geriatric syndromes is a detection practice proven effective in many countries. In Russia, the "Age is No Obstacle" questionnaire has been developed and validated (Appendix G5). A score of 3 or more on the "Age is No Obstacle" questionnaire requires referring the patient to a geriatric office; otherwise (0 – 2 points), the patient is consulted by a general practitioner or district therapist in accordance with clinical guidelines CG 613 "Frailty".

Comments: all patients with chronic pain exhibit an increased risk of falls [88], and the use of painkillers also leads to an increased risk [89, 90, 91]. A history of falls significantly increases the risk of recurrent falls. Clarifying the presence of gait changes and/or balance impairment, concerns about falling and/or the possibility thereof allows for the identification of patients at risk of falling who have not yet experienced a fall event in their history. To ensure the correction of specific modifiable fall risk factors, the patient may be referred for consultation with specialist physicians (a geriatrician, orthopedic traumatologist, neurologist, ophthalmologist, clinical pharmacologist, physical therapy physician, and others depending on the clinical situation).

Comments: in recent years, chronic musculoskeletal pain (back pain due to degenerative changes in the spine, joint pain due to osteoarthritis) in the elderly population has been viewed in close connection with the development and progression of sarcopenia [92, 93]. Pain itself can reduce patient activity, exacerbating sarcopenia; on the other hand, pathogenetic changes in muscles during sarcopenia (primarily the inflammatory cascade) can aggravate degenerative changes in cartilage and bone tissue [94, 95, 96]. Upper extremity muscle strength is assessed using handgrip dynamometry. The following dynamometry cutoff thresholds have been proposed for low muscle strength: less than 26 kg for men and less than 16 kg for women. Lower limb muscle strength is assessed using the 5-time sit-to-stand test. This test evaluates the time required for a patient to rise from a chair 5 times without using their arms. In clinical practice, the most widely used tool for assessing physical status is gait speed measurement. A gait speed of <0.8 m/s characterizes low muscle function.

Comments: for the differential diagnosis of neuropathic and nociceptive pain, it is necessary to use the following scales: the neuropathic pain diagnostic questionnaire Douleur Neuropathique 4 (DN4) (Appendix G6) and the painDETECT questionnaire (Appendix G7) [100, 101]. The diagnostic value of the questionnaires is moderate [102].

Comments: characteristics of the pain syndrome indicating neuropathic pain include: tingling and numbness in the distal extremities; sharp, shooting, pulsating, and burning (causalgic) pain; allodynia, hyperesthesia, pain and thermal hypesthesia [103, 104]. If neuropathic pain is suspected, the patient should be consulted by a neurologist.

Comments: signs of pain behavior include "coping strategies" that determine the patient's individual reaction to pain (pain catastrophizing, optimistic attitude, etc.), sleep disorders associated with the pain syndrome, and the degree of social maladaptation.

Comments: when planning chronic pain therapy in patients over 60 years of age, the impact of the pain syndrome on the functions and autonomy of a particular patient is of decisive importance [114]. Therefore, comprehensive documentation of the impact of pain on the functions of an elderly patient is crucial [115].

Comments: data from a number of studies [116, 117, 118] indicate that chronic pain can worsen patients' cognitive status. Diagnosis of cognitive impairment is included in the standard set of examinations during a comprehensive geriatric assessment. However, if the patient is not referred for a consultation with a gerontologist and will not undergo a standard geriatric examination, the attending physician must independently assess the degree of cognitive impairment. If present, it is necessary in the future to use cognitive function assessment when monitoring the effectiveness of pain therapy. There are no clinical studies confirming the reversibility of cognitive impairment upon pain relief.

2.2 Physical Examination

Visual and palpation assessment of local changes in any localization of the pain syndrome to assess the presence of inflammation symptoms (increased volume, redness, skin temperature); assessment of visual changes in the configuration and functions of joints and/or spine at the corresponding localization of the pain syndrome, measurement of anthropometric data (assessment of height loss, patient weight assessment), general thermometry.

2.3 Laboratory Diagnostics

Comments: a number of clinical and epidemiological studies have demonstrated an increased risk of OA [122, 124] at low vitamin D3 levels: OA risk (RR, 95% CI) — 1.4 (1.1–1.9), OA risk at high PTH level (RR, 95% CI) — 3.2 (1.8–4.1). This circumstance has a clear pathophysiological explanation. Cellular elements of joint tissue structures (chondrocytes, osteocytes, synoviocytes, etc.), as described above, also possess a high-affinity nuclear vitamin D receptor that regulates gene expression, including genes for pro-inflammatory cytokines. Vitamin D3 insufficiency leads to increased synthesis of pro-inflammatory and destructive mediators (cytokines) by joint tissues, and, consequently, increased inflammation and tissue destruction.

Comments: the radiological presentation of a vertebral body fracture in multiple myeloma is often identical to that of an osteoporotic fracture. The incidence of multiple myeloma, like osteoporosis, increases with age. If positive test results are detected, the patient should be referred for a consultation with a hematologist.

2.4 Instrumental Diagnostics

In general, older patients typically do not require diagnostic evaluations using highly specialized imaging methods. Special diagnostic methods may be prescribed by relevant specialists if there is a need to clarify anatomical structure changes. In patients with chronic pain, attention should be paid to "red flag symptoms" (unexplained weight loss, loss of appetite, fever, history of or current oncologic disease, history of immunosuppressive therapy, history of tuberculosis) requiring consultations with relevant specialists.

Comments: vertebral body deformation is regarded as a compression fracture if its height in the anterior, middle, or posterior section is reduced by 20% or more compared to the superior and inferior adjacent vertebral bodies [129, 131].

2.5 Other Procedures

Comments: due to the high prevalence of osteoporosis in individuals over 60 years of age, osteoporotic vertebral body fractures, and the high cost of treatment for this disease, screening for the risk of osteoporotic fractures is recommended in all individuals over 50 years of age, regardless of the presence of pain syndrome. Chronic back pain is one of the symptoms of osteoporotic damage to the bone structures of the spine.

Comments: OA is the most common pathology of the musculoskeletal system in individuals over 60 years of age. Diagnosing OA solely on the basis of complaints of pain in large joints is a clinical error. Radiological findings without the clinical picture of OA (pain, impaired function) are likewise not a reason to establish a diagnosis of OA.

Comments: synovitis can be a manifestation of both OA and systemic connective tissue diseases (e.g., rheumatoid arthritis), the diagnosis of which falls within the competence of a rheumatologist. Two-thirds of cases of exacerbation of joint pain syndrome are associated with the development of synovitis (effusive and noneffusive), which dramatically increases the intensity of destructive changes in the joints [138]. In some cases of effusive synovitis, diagnostic or therapeutic joint aspiration may be required, which must be coordinated and performed with a rheumatologist (in rare cases, with an orthopedic trauma surgeon).

Comments: currently, determining the localization and quantitative assessment of damage to the peripheral and central parts of sensory pathways is possible using electroneuromyography. The diagnostic value of ENMG in peripheral neuropathic pain is high [102]. To assess the state of thin fibers in neuropathic pain, it is necessary to use corneal confocal microscopy of the cornea [101] or skin biopsy [110]. To accurately determine the site of nerve damage or compression in neurological practice, ultrasound examination of the nerve is used [111].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Barriers to chronic pain management in patients over 60 years of age

Barriers to managing chronic pain characteristic of geriatric populations include age-related physiological changes leading to altered drug absorption and decreased renal excretion; sensory and cognitive impairments; polypharmacy and polymorbidity, particularly associated with such chronic conditions as cognitive impairment, gait disorders, as well as renal, pulmonary, and cardiovascular diseases [139].

Age-related pathophysiological changes affect therapy strategies because the pharmacokinetic and pharmacodynamic characteristics of drugs used to correct pain syndrome change. These include: altered renal function (at age 70, renal function decreases by 40–50% compared to 30-year-olds without kidney disease) [140]; age-associated physiological modifications of the gastrointestinal tract and liver affecting drug metabolism and availability [141]. These circumstances necessitate careful selection of analgesics and responsible titration of the dose from the minimum effective dose.

A particular problem is caused by so-called executive dysfunction, which frequently develops in patients with cognitive impairment. Executive dysfunction is a term that encompasses a wide range of frontal lobe-driven regulatory behaviors, including planning, organization, problem-solving, and decision-making [142]. Even mild forms of cognitive impairment may include executive dysfunction and represent a significant barrier to pain management.

Important obstacles to choosing pain therapy methods in elderly and senile individuals are the significant limitations of the evidence base, as well as physicians' concerns about the risk of adverse treatment effects [143], and the individual beliefs of older people regarding pain and analgesics [144]. Frequently, older people use unproven and ineffective pain treatments without consulting a medical professional, and seek medical care only in the event of severe pain or significant loss of autonomy.

Organizational barriers may include an insufficient number of specialized pain clinics. Most international guidelines include the position of referring the patient to a pain clinic if available pain relief techniques are ineffective, in order to perform minimally invasive procedures and methods involving group therapy.

3.2 Basic principles of chronic pain management in patients over 60 years of age

The general trend in recent years regarding the treatment of chronic pain, especially in older age groups, reveals a shift in the trend of medical interventions towards non-pharmacological therapy methods. This is due to advances in understanding the phenomenon of pain as a pathological condition resulting from the combined impact of biological, social, and psychological factors in the patient. Numerous studies published since the 1960s confirm the important role of psychological, behavioral, and social factors in the severity, persistence, and aggravation of pain. Despite a growing body of research, these factors are rarely taken into account when treating patients with chronic pain, especially those over 60 years of age. At different stages of disease progression, the relative weight of biological, psychological, and social factors may change. Thus, in the acute phase of the disease, biological factors predominate, but over time, psychological and social factors may come to the forefront. In this regard, chronic pain treatment aimed solely at the physical component of pain often proves ineffective. To achieve effective pain control, it is necessary to address not only physiological processes but also cognitive, emotional, and behavioral factors associated with chronic pain [145]. This applies to a greater extent to older patients, where the sum of polymorbid factors, cognitive impairment, anxiety-depressive disorders (including fear of pain), decreased mobility, and partial loss of autonomy become the main causes leading to the chronification and intensification of pain sensations. Therefore, non-pharmacological therapy, which provides for the development of an individualized patient management plan, is of the utmost importance in the treatment of chronic pain in patients over 60 years of age.

3.3 Patient communication

An important issue for developing an individualized chronic pain treatment plan is sharing responsibility for treatment outcomes with the patient (caregiver, family members, loved ones—depending on willingness to participate in the treatment process). Shared responsibility is a new trend in pain management strategies.

First of all, it is necessary to determine the expected outcome of chronic pain treatment (complete relief from pain, restoration of functions, increased mobility, restoration of autonomy, alleviation of anxiety and depression symptoms, etc.), which depends on the polymorbidity, geriatric status, and cognitive capabilities of the patient. This issue must be discussed with the patient and their loved ones.

Of no lesser importance is the style of the physician's conversation with the patient. It is necessary to adjust the conversation structure, terminology used, and style to the patient's level of education, intellect, and communication skills.

It is worth explaining to the patient that non-pharmacological treatment methods currently occupy primary positions in therapy from the standpoint of accumulated evidence and broad international experience. The clinician should not be limited merely to recommendations on increasing physical activity and the need to perform exercises. Specific exercise routines should be suggested (visualization of the exercise technique is required for some patients), and the duration and conditions of training should be discussed (it is also useful to advise on clothing and footwear comfortable for performing exercises). Whenever possible, benchmarks for monitoring the effectiveness of non-pharmacological treatments should be selected.

When prescribing medications, the patient must be warned about the risk of potential adverse effects. It will be useful to analyze the pros and cons of choosing specific medications together with the patient.

One should not discuss the financial burden of the chosen therapy strategy with the patient.

Remind the patient of the need to inform medical staff about worsening well-being and/or the appearance of new symptoms.

It is advisable to discuss with the patient which areas of everyday and social life are impaired due to pain sensations, and to give advice on modifying and adapting certain aspects of everyday and social activity [146].

3.4 Non-pharmacological treatment

It should be noted that the modern arsenal of non-pharmacological therapy contains a fairly large list of methods that will not be reflected in these guidelines, since the organizational aspects of their use are not regulated in the national healthcare system for patients over 60 years of age. Nevertheless, given the development of the medical rehabilitation service, the emergence of geriatric inpatient facilities and outpatient clinics, and the rethinking of the work of hospitals for war veterans, a list of methods used in the treatment of chronic pain in older age groups should be provided. These include: massage, acupuncture, laser therapy, electromagnetic stimulation, balneotherapy, manual therapy, therapeutic taping, thermotherapy, the use of braces and orthoses, and the use of orthopedic insoles. There are separate clinical studies demonstrating the effectiveness of these methods in the complex treatment of chronic pain. However, the strength of evidence for these recommendations in patients over 60 years of age needs to be verified in future RCTs and systematic reviews. To date, we do not have convincing data on the effectiveness of these methods [147], but we conditionally recommend considering their necessity when planning an individual chronic pain treatment plan in patients over 60 years of age.

Comments: an individual pain management plan is a multimodal approach that includes not only the treatment of the underlying disease that resulted in the patient developing a pain syndrome, but also the treatment of comorbid conditions and geriatric syndromes, and methods to increase patient mobility. Based on the CGA [152] the need for care and a patient monitoring plan should be determined. Assessment of social and family status will expand treatment opportunities by involving family members and loved ones.

Comments: international experience in the development of geriatric care clearly demonstrates an increase in the effectiveness of measures carried out within the framework of an interdisciplinary geriatric team. The competencies and professional skills of these specialists make it possible to draw up the most complete and effective individual chronic pain treatment plan in older patients.

Comments: The diet of a patient with chronic pain should be varied, including meat and fish dishes, and dairy products (in patients with hyperuricemia, the amount of protein-rich foods should be considered in detail). The amount of protein required to maintain muscle mass in older patients is 1.0-1.5 g/kg per day, except for patients with chronic kidney disease, in whom the protein diet should be optimized taking into account the degree of renal impairment. Total fluid intake should be at least 2 liters (including meals and food products), with pure fluids accounting for at least 800 ml. For patients with heart failure, fluid intake must be agreed upon with a general practitioner or cardiologist. In patients with malnutrition, the caloric value of the diet should be increased up to 3000 kcal per day. The use of protein-energy supplements in patients with chronic pain and frailty has a positive effect on slowing down the progression of frailty and sarcopenia without a negative effect on serum urea levels and creatinine clearance [158, 159, 160]. Recommendations aimed at reducing the risk of falls should include: consultations with specialists (ophthalmologist, otorhinolaryngologist, urologist, gynecologist) to address sensory deficits and urinary tract pathology; selection of comfortable furniture height (beds, armchairs, toilet, etc.); ensuring furniture stability; installation of handrails, especially in the toilet and bathroom; use of non-slip floor coverings; selection of traumatic-safe floor coverings (e.g., carpeting); elimination of thresholds where possible; adequate, but not too bright lighting; contrast markings on stairs and steps.

Comments: Loneliness and social isolation are major factors in ineffective pain management and the progression of frailty. Patients should be advised to contact social service centers for leisure activities and to increase social activity.

Comments: one randomized clinical trial showed that physician and patient education, activation, and symptom monitoring in primary care patients with chronic pain were associated with reduced disability, decreased pain intensity, and fewer symptoms of depression over 12 months of follow-up [149]. Therapeutic interventions targeting patients with chronic pain increasingly involve the family, most commonly by including relatives in cognitive behavioral therapy or self-management training. Although the evidence is mixed, several randomized trials suggest that spousal involvement in treatment can yield tangible benefits for patients, including improved emotional well-being and reduced pain levels [166, 167].

Comments: the most thoroughly studied is the Tai Chi exercise program, which consists of continuous, smooth movements requiring the individual's full concentration. Studies describe Tai Chi as an effective method for reducing chronic back and joint pain in patients over 60 years of age and helping them resume an active lifestyle. Tai Chi has been shown to be more effective in complex pain therapy than walking or jogging. Additionally, aerobic exercise programs aimed at training muscle strength and endurance (depending on the pain localization) can be used for daily 10–15 minute sessions. Daily performance of a therapeutic exercise program is the foundation of chronic pain management regardless of localization. In the treatment of pain associated with osteoarthritis (hip joint, generalized osteoarthritis), Tai Chi is the most evidence-based recommendation [179]. A special exercise program should be selected in consultation with a physical therapist. The Tai Chi program is not a complete alternative to a daily aerobic exercise program aimed at strength and endurance training. These physical activity methods should be combined. The patient's cardiovascular risk, presence of respiratory diseases, and other comorbid risks must be considered when selecting the most sparing exercise regimens.

Comments: this recommendation should be applied taking into account the polymorbid and geriatric status of the patients and the availability of a physical therapist skilled in developing water-based exercise programs. There is insufficient data on the efficacy of water-based exercises in patients with frailty. It is most likely advisable to refrain from this type of treatment in patients with frailty due to the high risk of injury and emergencies. These exercises should be recommended under the supervision of a third party capable of providing necessary assistance in situations requiring outside help. It is not recommended to conduct these exercises in a pool with a depth exceeding 2/3 of the patient's height. Group classes should be recommended.

Comments: psychotherapy is a complex method of psychotherapeutic intervention. These therapy methods may be administered by neurologists or psychiatrists who have undergone appropriate training. It is inappropriate to entrust psychotherapy to psychologists or other specialists lacking the relevant qualifications. These therapy methods are highly effective and backed by substantial evidence when conducted in accordance with recommended techniques. Conducting cognitive-behavioral sessions in small groups of patients with similar medical problems is important.

Comments: chronic pain therapy, like any therapy in patients over 60, aims to enhance autonomy, increase mobility, improve quality of life, and reduce dependence on outside help. Achieving mobility is often impossible without the use of orthopedic devices and low-tech assistive aids. In patients with toe deformities, wearing traditional shoes without orthopedic devices causes pain that limits mobility (patients stop leaving the house). Special aids and footwear that facilitate their use should be recommended, and the strategy for expanding mobility should be coordinated with an orthopedist. Patients with a fear of falls (and/or a history of falls) drastically restrict their mobility; appropriate walking aids (canes, walkers, specialized footwear) should be selected for them to reduce the risk of falls.

3.5 Pharmacological treatment

Pharmacological treatment of mild to moderate musculoskeletal pain should be initiated only if non-pharmacological therapy methods have proven ineffective.

Pharmacotherapy for neuropathic pain may be considered at the very first contact with the patient, but the choice of drugs and their dosing regimen is best carried out within an interdisciplinary geriatric team (or after consultation with specialized physicians, such as a neurologist or endocrinologist).

Patients with cancer pain should be consulted by a palliative care physician, which will allow for the selection of the most appropriate pain management strategy, taking into account the phased selection of analgesics. The decision to prescribe opioid analgesics should be made during a medical panel (consilium) with a palliative care physician, in accordance with the current clinical guidelines of the Russian Ministry of Health "Chronic Pain Syndrome (CPS) in Adult Patients Requiring Palliative Care." These guidelines provide a methodological approach to determining the need for opioid analgesics and selecting specific drugs depending on the severity of the patient's clinical status, pain intensity, and refractoriness to other pain management methods. Since the palliative care physician is the primary specialist, their participation in developing the patient's individual treatment plan is advisable.

In any situation, the choice of analgesics must account for polypharmacy, which is common in patients over 60 with chronic pain, and the STOPP/START criteria when prescribing analgesics [193].

Comments: recommendations on prescribing paracetamol** are standard in most global geriatric associations. Paracetamol** should be prescribed at a daily dose of 3 grams, and in patients with frailty or older than 80 years - no more than 2 grams per day. Patients must be warned about the presence of paracetamol** in most antipyretic drugs and combination analgesics to ensure more accurate monitoring of the daily dose. It should be noted that in one systematic review for back pain and OA, paracetamol** did not confirm its efficacy [195], however, more recent systematic reviews have proven the analgesic potential of the drug in the same pathologies [196].

Comments: most NSAIDs have convincingly proven their efficacy in the treatment of acute and chronic pain, including in individuals over 60 years of age. However, Category A adverse effects (gastrotoxicity, nephrotoxicity, thromboembolic complications, blood pressure elevation) combined with pharmacokinetic alterations in older age groups require an extremely rigorous analysis of the clinical situation and a careful weighing of the risk of adverse effects. For the same reason, NSAIDs should not be prescribed in long courses. The safest NSAIDs should be selected and prescribed in the minimum doses sufficient to produce an analgesic effect. Although the prescription of NSAIDs to individuals over 60 carries a conditional recommendation grade, most international guidelines, in sections related to good clinical practice, indicate the necessity of prescribing NSAIDs in a number of clinical situations.

Comments: the high risk of adverse effects when prescribing NSAIDs in these patient groups outweighs the benefit of their use. These clinical situations represent absolute contraindications for prescribing NSAIDs. Alternative pain relief methods should be chosen or the patient should be referred to a pain clinic and/or a specialized physician (neurologist, rheumatologist, orthopedist, oncologist, palliative care physician).

Comments: all NSAIDs increase the risk of fluid retention and blood pressure destabilization (Category A adverse effect). Patients with chronic kidney disease and/or diabetes mellitus are of particular concern. It is advisable to instruct the patient to measure blood pressure 3-4 times a day on the days of NSAID intake and recommend contacting the attending physician if the blood pressure does not correspond to the individual target level. It should be remembered that amlodipine** helps improve blood pressure control when prescribing NSAIDs and should be included in the complex antihypertensive therapy of a patient with chronic pain syndrome.

Comments: The risk of acute erosive and ulcerative lesions of the gastroduodenal mucosa during NSAID intake increases sharply in elderly patients with aortic atherosclerosis and heart failure, which lead to chronic ischemia of the gastroduodenal mucosa. If side effects from NSAIDs occur, the indications for their use must be reviewed first; if discontinuation of the drug is impossible, its dose should be reduced or a drug with the fewest side effects should be prescribed. Complete cessation of NSAID intake does not in itself lead to the resolution of NSAID-gastropathy in the majority of patients. When choosing proton pump inhibitors for a patient with combined (rheumatic, cardiological, and neurological) pathology, drug interaction characteristics play a major role. Of importance is the effect on the liver isoenzyme CYP2C19, since it is involved in the metabolism of a significant number of drugs. It has been shown that omeprazole** and, partially, lansoprazole slow down the metabolism of carbamazepine**, cyclosporine**, diazepam**, digoxin**, nifedipine**, phenytoin**, theophylline, warfarin**, and clopidogrel**. In addition, the pH selectivity of proton pump inhibitors is important; its low value is discussed as a pathogenetic mechanism of potential side effects during long-term proton pump inhibitor therapy, because proton pumps (H+/K+- or H+/Na+-ATPases) besides parietal cells are found in cells of other organs and tissues: in the epithelium of the intestine and gallbladder, renal tubules, corneal epithelium, muscles, cells of the immune system (neutrophils, macrophages, and lymphocytes), osteoclasts, etc.

Comments: the efficacy and safety of pregabalin and gabapentin have been reliably studied in older age groups. Therapy should be started with minimal doses (pregabalin** – 75 mg, gabapentin – 300 mg), gradually titrating the dose until an analgesic effect develops (maximum doses in RCTs for pregabalin** – 600 mg, gabapentin – 1800 mg). In the first days of intake, psychotropic effects and lethargy may develop. Driving vehicles is not recommended while taking these drugs. For an approximate algorithm of neuropathic pain therapy, see Appendix A.

Comments: neuropathic pain therapy should be coordinated with a neurologist.

Comments: The possibilities of combined treatment with antiepileptic drugs and antidepressants are indicated in a number of clinical guidelines. However, this therapy is associated with an increased risk of adverse effects in elderly and senile patients, especially the risk of falls. The decision on the necessity of this therapy must be made collegially with a neurologist. In addition, patients on combination therapy with these drugs should be monitored more closely, and more robust measures should be implemented to reduce the risk of falls and prevent cognitive impairment.

Comments: venlafaxine is not recommended due to the risk of hyponatremia, dizziness, and abdominal pain. A number of studies have indicated a prohypertensive effect of venlafaxine in older age groups.

Comments: among patients over 60 years of age taking benzodiazepine derivatives, there is an increased risk of falls (by 20%) and cognitive impairment.

Comments: a meta-analysis of 41 RCTs [233] evaluating the efficacy of opioids for the treatment of various forms of chronic non-cancer pain, including osteoarthritis, diabetic neuropathy, back pain, and rheumatoid arthritis, demonstrated that on average, opioids may lead to a small reduction in pain intensity and functional improvement compared to placebo, and to a similar reduction in pain, but lesser functional improvement compared to other analgesics.

Comments: high-quality data involving a large number of patients showed small benefits for a course exceeding 12 weeks. Careful monitoring of the number of joints to which the topical NSAID is applied, as well as the concomitant use of any oral NSAIDs, is necessary due to the potential risk of exceeding the total recommended NSAID doses. The most frequent side effects associated with the use of topical NSAIDs were local skin reactions, which were minor and transient in nature.

Comments: topical forms of lidocaine at a concentration of at least 5% are able to reduce the intensity of neuropathic pain, including cases of postherpetic neuralgia. The use of creams and patches is recommended. Mild skin reactions may develop, disappearing after discontinuation of use.

Comments: colecalciferol and its analogues are among the best-tolerated and safest agents. Side effects of vitamin D therapy include: hypercalcemia, increased liver enzyme activity, elevated urea and creatinine levels, and less commonly, pruritus, rash, and increased blood pressure. When prescribing these agents, it is necessary to monitor calcium, phosphorus, and creatinine levels, as well as transaminase and alkaline phosphatase activity. If side effects occur or if the calcium level rises above 2.75 mmol/L, it is recommended to discontinue treatment for 7–10 days and then resume it using a dose reduced by 50%, while monitoring the patient's general condition and blood calcium levels.

Vitamin D deficiency corresponds to a 25(OH)D₃ concentration of <20 ng/mL (50 nmol/L), vitamin D insufficiency to 25(OH)D₃ from 20 to 30 ng/mL (from 50 to 75 nmol/L), and an adequate level to >30 ng/mL (75 nmol/L). The recommended target 25(OH)D₃ level during vitamin D deficiency correction is 30–60 ng/mL (75–150 nmol/L). To prevent vitamin D deficiency, it is recommended to prescribe at least 800–1000 IU of vitamin D or its derivatives per day; maintaining a 25(OH)D level above 30 ng/mL may require an intake of at least 1500–2000 IU of vitamin D per day. The recommended drug for treating vitamin D deficiency is colecalciferol**. Treatment of vitamin D deficiency in adults is recommended to start with a total loading dose of colecalciferol** of 400,000 IU, followed by a transition to maintenance doses

Comments: Most CS is available in oral formulations, the bioavailability of which, according to clinical studies, is 13–38% due to the breakdown of CS molecules in the gastrointestinal tract [249]. Intramuscular (IM) administration of the drug increases the bioavailability of CS, which can not only enhance therapeutic efficacy but also lead to a more rapid symptomatic effect. Pharmaceutical-grade parenteral chondroitin sulfate formulations, whose efficacy has been proven in RCTs, are available in the RF [250]. To relieve joint pain, it is recommended to use parenteral forms of chondroitin sulfate at a dose of 100–200 mg daily, every other day, with a total course duration of 25–30 injections. The available evidence relates primarily to knee osteoarthritis, whereas evidence for hip OA is insufficient. The use of chondroitin sulfate may also be recommended for patients with generalized osteoarthritis and geriatric frailty [179].

Comments: available evidence for the efficacy of glucosamine in joint pain pertains to the pharmaceutical substance [253, 254]. It is advisable to use oral formulations at a dose of 1500 mg daily for 12 weeks; the course can be repeated at 2-month intervals. The clinical effect size for glucosamine in pain, estimated from placebo-controlled trials, can be considered moderate at 0.27 (SMD and fixed-model meta-analysis), but it is greater than that of paracetamol** (with a clinical effect size starting from 0.14; 95% CI 0.05–0.22) [255] and in the same range as short-term oral NSAID administration (clinical effect size 0.29; 95% CI 0.22–0.35) [252]. Recently published studies demonstrate that glucosamine can be used as an adjuvant agent when prescribing NSAIDs, leading to analgesic and anti-inflammatory effects at lower NSAID doses [256]. Pharmaceutical-grade parenteral glucosamine formulations, the efficacy of which has been proven in RCTs, are available in the RF [257].

Comments: intra-articular administration of glucocorticosteroids can provide short-term pain relief, whereas intra-articular administration of hyaluronic acid preparations reduces pain for over 12 weeks post-injection and has a more favorable long-term safety profile than repeated intra-articular injections of glucocorticosteroids [179].

Comments: intra-articular administration of stem cells and PRP (platelet-rich plasma) is strongly discouraged because the evidence base for these methods is of extremely low quality, and the products themselves are not yet standardized. Further research is needed to assess the appropriateness of these treatments for OA.

Comments: Oral bisphosphonates (alendronic acid**) can be used as initial treatment in most cases. In women who do not tolerate oral bisphosphonates (or in whom they are contraindicated), intravenous bisphosphonates (zoledronic acid**) or denosumab** are indicated. HRT is considered as an additional option. Treatment should be reconsidered after 3–5 years of bisphosphonate therapy. The risk of new fractures increases in patients who discontinue treatment. Discontinuation of denosumab** therapy is associated with a rebound in vertebral fracture rates. Bisphosphonate therapy should be considered after discontinuing denosumab**. There is little evidence to guide decision-making beyond 10 years of treatment, and treatment options for such patients must be considered on an individual basis.

3.6 Other treatment

In routine clinical practice for chronic joint and back pain in our country, products classified as dietary supplements are used (e.g., avocado and soybean unsaponifiables; combination products of chondroitin sulfate, glucosamine hydrochloride with/without MSM, collagen, diacerein, eggshell membrane extract, etc.). The prescription of these agents cannot be regulated by clinical guidelines. It is appropriate to use them as needed in specific situations, depending on patient preferences. The final decision on intake must be made by the patient. The physician must inform the patient about potential risks of adverse effects and the range of therapeutic activity.

This position also applies to oral products containing the vitamin B complex (with or without uridine), which are traditionally used in combination therapy for back pain to stimulate remyelination of damaged nerve fibers (e.g., in radiculopathy). Although a number of reliable RCTs have demonstrated significant efficacy of complex B vitamin preparations (with or without uridine), the final decision on intake must be made by the patient. A patient's refusal to take these agents should not be regarded as a violation of the prescribed treatment protocol.

3.7 Surgical treatment

Comments: age is not a contraindication or limitation for joint replacement arthroplasty. The efficacy of total joint replacement in treating pain is beyond doubt. Restoration of joint function depends on the patient's baseline physical and functional status, as well as the scope of postoperative rehabilitation interventions. However, a recently published systematic analysis [274] demonstrated that the presence of frailty is a predictor of adverse outcomes following arthroplasty. Patients with frailty and/or other geriatric syndromes require careful preoperative preparation, taking into account multimorbidity risks, functional and physical status. It is necessary to weigh the availability, capability, and ability of the patient to undergo postoperative rehabilitation. If the patient is unable to perform postoperative rehabilitation measures, the necessity of surgical intervention remains questionable. The patient's expectations and the likely outcome of the surgical intervention should be aligned. The clinical decision regarding the need for joint replacement is best made by a concilium of dedicated specialists or discussed within an interdisciplinary geriatric team. The patient must be informed about all potential risks associated with the surgery and the perioperative period. In the postoperative period, patients with geriatric syndromes require monitoring by a geriatrician and adherence to the prescribed rehabilitation regimen.

Comments: the use of minimally invasive procedures associated with denervation is contraindicated in patients with frailty and severe multimorbid conditions. Furthermore, there are no data on the efficacy of these procedures in patients older than 80 years. In some cases, these therapies may be considered as an alternative to opioid therapy in palliative care. However, this position also lacks an evidence base. Undoubtedly, more controlled trials are needed to evaluate the efficacy and safety of these chronic pain treatments in patients over 60 years of age.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Medical rehabilitation of patients over 60 years of age with chronic pain involves the prolonged application of the specified non-pharmacological therapies (see the relevant section).

Comments: currently, rehabilitation measures begin within 24 hours after surgery. As a rule, before discharge from the hospital, the patient is taught to walk, and weight-bearing function is restored. The return of a full (or sufficient) range of motion occurs gradually over the next 3–6 months. It is advisable to recommend specialized rehabilitation programs within rehabilitation centers or sanatorium-based treatment.

Adequate physical rehabilitation of patients remains the most important aspect of postoperative patient management. Physical rehabilitation is not only an intervention that allows the patient to return to active movement in the operated joint, but also the most effective and reliable method of secondary prevention of OA. As a rule, upon discharge from the hospital, the patient has a physical exercise plan proposed by the physical therapy physician in the surgical hospital. However, this initial set of exercises, aimed at activating the muscular apparatus in the operated limb, is designed for a short duration.

The usual set of exercises for patients is related to activating the muscular system and consists of muscle tension and relaxation complexes, a minimal level of stretching of the musculoligamentous apparatus, abduction and adduction in the joint, and small-range rotations. Particular attention should be paid to exercises related to the functional activity of the joints. While simulation of joint activity is permitted in the first weeks (joint movements with the assistance of an instructor or helper), patients should subsequently be more actively encouraged to perform functional loads. When possible, the therapeutic exercise program should be expanded weekly, incorporating a larger number of joints into the training. It should be noted that the use of devices (braces, orthoses, etc.) that reduce mechanical stress is permitted and, in some cases of polyarthritis, necessary.

Most methodologies divide rehabilitation measures into several phases:

1. Phase 0 of rehabilitation (exercises performed immediately after surgery, on the same day the surgery was performed).
2. Phase 1 of rehabilitation: "strict care" (1–4 days postoperatively).
3. Phase 2 of rehabilitation: "deceptive opportunities" (5–21 days postoperatively).
4. Phase 3 of rehabilitation: "getting to work" (4–8 weeks postoperatively).
5. Phase 4 of rehabilitation: "full recovery" (9–14 weeks postoperatively).

Obviously, strict adherence to the physical rehabilitation protocol prescribed by a physician must be maintained for up to 14 weeks.

The lack of adequate functional recovery after surgical treatment, a number of complications, and pain recurrences are often associated precisely with the absence of a rehabilitation program.

5. Prevention and Dispensary Observation

5.1 Prevention

Issues of chronic pain prevention pertain to chronic non-cancer pain, including musculoskeletal pain syndrome and neuropathic pain.

Comments: physical activity measures for individuals over 60 years of age are necessary preventive interventions to prevent the development of all geriatric syndromes. A significant effect in preventing chronic back pain has been demonstrated for aqua aerobics exercises [184]. Aerobic and resistance training are effective in preventing diffuse pain, including fibromyalgia [287]. Yoga-based exercises (including Tai Chi) prevent the development of joint pain [288, 289].

Comments: referral to specialized support centers and the use of smoking cessation aids (sprays, patches) should be recommended. However, data on their efficacy and safety in older age groups are lacking. Alcohol abuse is a significant limitation for prescribing all drug classes used for chronic pain (increased risk of psychogenic adverse effects, liver damage) [295].

5.2 Dispensary monitoring

Patients with chronic pain syndrome do not require active dispensary monitoring. Dispensary monitoring should be carried out for the underlying disease that led to the onset of pain, in accordance with current clinical guidelines.

6. Organization of Medical Care

Indications for planned inpatient hospitalization of a patient over 60 years of age

1. Moderate or low-intensity chronic pain of undetermined origin for diagnostic purposes when necessary diagnostic procedures are unavailable in the outpatient setting
2. Moderate or low-intensity chronic pain for invasive interventions aimed at treating the pathology that caused the pain

Indications for emergency inpatient hospitalization of a patient over 60 years of age

1. High-intensity pain of previously undiagnosed etiology
2. High-intensity pain requiring adjustment and intensification of analgesic therapy
3. Combination of pain syndrome with non-specific symptoms such as fever, weight loss, loss of appetite, as well as a history of cancer or receiving immunosuppressive therapy, with an undetermined cause of pain
4. Development of complications associated with pain (e.g., arrhythmias) or analgesic medications (e.g., NSAID-induced bleeding)

Indications for hospitalization in a medical organization providing inpatient specialized palliative medical care for patients over 60 years of age

1. Intense chronic pain in patients with medical indications for palliative medical care, in accordance with Order No. 345n of the Russian Ministry of Health and No. 372n of the Russian Ministry of Labor dated May 31, 2019 (the decision is made jointly with a palliative care physician).

Indications for discharging a patient from a medical organization are determined based on:

1. the patient's condition,
2. completion of the diagnostic process,
3. performance of an invasive intervention,
4. the achieved result of treatment or examination.

It should be remembered that hospitalization of older age groups is always associated with an increased risk of infectious diseases, depression, and the development of geriatric delirium. Therefore, hospitalization periods should be minimized for all patients over 60 years of age.

7. Additional Information

Adverse consequences of chronic pain syndrome associated with difficulties in achieving adequate pain relief include:

• sleep disturbances,
• anxiety disorders,
• kinesiophobia,
• depression,
• cognitive impairment,
• delirium.

Correction of these conditions is necessary for all patients with chronic pain; it is advisable to discuss patients in an multidisciplinary geriatric team (medical board of specialists), with the participation of a neurologist, psychotherapist, general practitioner, and geriatrician.

The presence of delirium leads to increased mortality and the need for long-term care. The most vulnerable category of patients consists of those with cognitive impairment.

Delirium in older age groups with chronic pain most often presents in a hypoactive form, which is why it goes unrecognized by medical personnel. The Confusion Assessment Method (CAM) (Appendix D) is used for delirium screening. To prevent the development of delirium, it is advisable to implement measures aimed at proper orientation of the patient in time (a clock and a calendar with the current date should be in the patient's field of view) and space, contact with the patient, ensuring access to daylight during waking hours, maintaining wake-sleep cycles, creating a favorable environment for night sleep, correction of sensory deficits (providing glasses and hearing aids if necessary), opportunities for communication with relatives (pre-explaining the features of the patient's condition to them), early mobilization of the patient after surgical intervention, adequate fluid intake, and ensuring comfortable psychological conditions (avoiding excessive noise, bright light, and maintaining a benevolent attitude).

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Tkacheva, O.N. – MD, Professor, Director of the Russian Gerontology Clinical Research Center of the Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Head of the Department of Aging Diseases of the Pirogov Russian National Research Medical University of the Ministry of Health of Russia, President of the Russian Association of Gerontologists and Geriatricians
2. Naumov, A.V. - MD, Head of the Laboratory of Musculoskeletal Diseases of the Russian Gerontology Clinical Research Center of the Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Professor of the Department of Aging Diseases of the Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians
3. Kotovskaya, Yu.V. – MD, Professor, Deputy Director for Scientific Work of the Russian Gerontology Clinical Research Center of the Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians
4. Runikhina, N.K. – MD, Deputy Director of the Russian Gerontology Clinical Research Center of the Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Professor of the Department of Aging Diseases of the Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians
5. Milto, A.S. – MD, Chief Physician of the Russian Gerontology Clinical Research Center of the Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Professor of the Department of Aging Diseases of the Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians
6. Aleksanyan, L.A., MD, Professor, Deputy Director for Organizational and Methodological Work of the Russian Gerontology Clinical Research Center of the Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians
7. Khovasova N.O. – PhD in Medicine, Associate Professor at the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Senior Researcher at the Laboratory of Musculoskeletal Diseases, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Russian Ministry of Health, member of the Russian Association of Gerontologists and Geriatricians
8. Moroz V.I. – Assistant at the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Junior Researcher at the Laboratory of Musculoskeletal Diseases, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Russian Ministry of Health, member of the Russian Association of Gerontologists and Geriatricians
9. Manevich T.M. – PhD in Medicine, Head of the Neurology Department, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Russian Ministry of Health, member of the Russian Association of Gerontologists and Geriatricians
10. Rozanov A.V. – Cand. of Sci. (Med.), Senior Research Associate, Laboratory of Cardiovascular Aging, Pirogov Russian National Research Medical University of the Russian Ministry of Health (RGNKC branch), Member of the Russian Association of Gerontologists and Geriatricians
11. Ostapenko V.S. – Ph.D. (Medicine), Head of the Department of Geriatrics, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Assistant Professor at the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians
12. Meshkov A.D. – PhD in Medicine, Senior Researcher at the Laboratory of Musculoskeletal Diseases, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Russian Ministry of Health, member of the Russian Association of Gerontologists and Geriatricians

All members of the Working Group have confirmed that they have no financial support or conflicts of interest to disclose.

The draft clinical guidelines have been posted for public discussion on the website www.rosagg.ru. Public discussion of the clinical guidelines took place during the 4th All-Russian Congress of Gerontology and Geriatrics with International Participation on May 21–24, 2020.

Appendix A2. Methodology for Developing Clinical Guidelines

The clinical guidelines were developed by expert specialists of the Russian Association of Gerontologists and Geriatricians.

This version of the clinical guidelines is based on the following resources and documents:

- 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

- The International Association for the Study of Pain, https://www.iasp-pain.org/GlobalYear/PaininOlderPersons

- P. Schofield. The Assessment of Pain in Older People: UK National Guidelines, Age and Ageing, Volume 47, Issue suppl_1, March 2018, Pages i1–i22, https://doi.org/10.1093/ageing/afx192

- Abdulla A, Adams N, Bone M et al. Guidance on the management of pain in older people. Age and ageing 2013; 42: i1–i57. March 2013.

- Hadjistavropoulos T, Herr K, Turk DC, Fine PG, Dworkin RH, Helme R, et al. An interdisciplinary expert consensus statement on assessment of pain in older persons. Clin J Pain 2007.23(1):1-43

Sources for recent updates included journal publications in reputable peer-reviewed journals indexed in Russian and international citation databases.

Target audience for these clinical guidelines:

1. Geriatrician in medical organizations providing outpatient and inpatient care.
2. General practitioner/internist of medical organizations providing care in outpatient and inpatient settings.
3. General practitioner (family physician).
4. Physical therapist in medical organizations providing outpatient and inpatient care.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Levels of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Grades of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

Clinical guidelines are updated once every 3 years, taking into account new Russian and international data on the epidemiology of disease forms, diagnostic methods and tactics, pharmacological treatment options, and indications for surgical interventions.

Appendix A3. Reference Materials

Related Documents

Order of the Ministry of Health of the Russian Federation No. 38n dated January 29, 2016, "On Approval of the Procedure for Providing Medical Care in the Field of 'Geriatrics'."

Order of the Russian Ministry of Health No. 1067n dated December 20, 2019, "On Amendments to the Procedure for Providing Medical Care in the Field of 'Geriatrics' approved by Order of the Russian Ministry of Health No. 38n dated January 29, 2016"

Clinical Guidelines CG 613 "Frailty"

Clinical guidelines "Falls in elderly and senile patients"

Methodological Guidelines MP 103 "Pharmacotherapy in Elderly and Senile Patients"

Appendix B. Physician Action Algorithms

Appendix B1 Fall risk assessment algorithm for patients over 60 years of age with chronic pain

Appendix B2 Sarcopenia diagnostic algorithm

For the SARC-F questionnaire, see Appendix G11

DXA – dual-energy X-ray absorptiometry (Whole Body scan)

BIA – bioelectrical impedance analysis

Appendix C. Patient Information

Basics of patient education for chronic non-cancer pain:

1. Ensure a safe home environment for moving around day and night. Remove rugs and obstacles from your path. Provide lighting along the path to the bathroom and kitchen at night. If necessary, use individual mobility aids (cane, walker, etc.).
2. Upon waking up or after prolonged sitting, before standing up, gently move all joints in various directions, flexing and extending your knees.
3. One hour after breakfast, 30 minutes before, perform your individual exercise routine.
4. Move more. Stay active even if you are bothered by pain.
5. Try to walk at least 3 km a day at a comfortable pace. This will provide a significantly greater analgesic effect than taking medications. This fact has been proven in large studies and is widely used by doctors worldwide.
6. If joint pain has worsened, examine the joint. It may be swollen, red, or warm to the touch. Seek medical attention immediately.
7. Keep a pain diary; this will allow you and your doctor to analyze your pain syndrome more thoroughly. In the morning and evening, record the pain intensity (use a scale where 0 = no pain, 100 = worst pain imaginable). If the pain has increased, note this in the diary, describe where it increased, under what circumstances, what you did about it, and whether the measures helped.
8. If joint pain is severe, use topical analgesics. Record the use of topical NSAIDs in your diary.
9. If your joint aches persistently, use a long-acting pain-relief patch (e.g., 12 or 24 hours). Apply it to the painful joint. Before doing so, try to flex and extend the joint several times.
10. Be sure to use orthopedic footwear or orthopedic insoles. You can purchase them at orthopedic stores. If your body geometry is impaired, the progression of your joint disease will accelerate.
11. In case of severe knee pain, braces can be used for walking. They will reduce the load on the joints.
12. Perform your individual exercise routine for 20 minutes before bedtime.
13. Swimming is highly recommended. Try to swim 1–2 hours a week. Backstroke is preferred, as it prevents overloading the cervical spine.
14. Try to eat sea fish 2–3 times a week. Your diet should be enriched with dairy and fermented milk products. You need plenty of greens, bell peppers, cucumbers, and carrots. Prepare aspic or jellied poultry or fish dishes more often (2–3 times a month). Pork aspic is not suitable for you. Reduce your intake of salt, pasta, and semolina. Eat more buckwheat, rice, lentils, and beans. Mushrooms and moderate meat consumption are indicated.
15. Whenever possible, processed foods should be excluded from the diet: sausages, smoked meats, fast food. If you cannot live without sandwiches, the best substitute for sausage is oven-baked meat or, if you don't mind the effort, homemade sausages made from natural meat. When cooking, use preparation methods that leach out harmful substances as much as possible. Remove the skin from poultry and trim the fat from meat. Then use boiling, stewing, steaming, oven baking, and grilling.
16. Preservatives cause the deposition of uric acid crystals in the joints, which impair the quality of synovial fluid, irritate the joints, and cause inflammation.
17. It is necessary to monitor the levels of uric acid, vitamin D₃, and hemoglobin.
18. Try to watch more movies and TV shows. Go to the cinema for a 3D movie. If possible, play computer games for at least 30–40 minutes a day. Solve crossword puzzles. Go out and invite guests over.
19. Patients with osteoporosis are advised to attend an Osteoporosis School. Find out about such schools in your region.
20. Patients with Diabetes Mellitus are advised to attend a Diabetes School. Find out about such schools in your region.

Physical therapy programs for patients with OA

Each joint exercise should be performed 6–8 times, 2–3 times a day at a calm pace. Monitor your breathing; it should be free, without holding your breath.

Patients with polyarthritis are recommended to walk 3 kilometers daily at a calm pace (supportive aids like Nordic walking poles can be used). This specific distance has strong scientific justification. It is recommended to take 20–30 minute walks daily, increasing the distance and time once a week. With fast walking, the load on the joints begins to exceed body weight by 1.5–2 times, making an intensive walking pace contraindicated for patients with OA.

Patients with OA are recommended to swim for 40–45 minutes, twice a week. If the patient cannot swim, they can participate in water aerobics classes.

The best fitness center programs for OA patients are medium- and low-intensity Pilates programs (muscle-stretching exercise complexes). Cycling, in addition to its beneficial effects on joints, brings a positive emotional boost. Riding on uneven terrain should be avoided. Bouncing movements are harmful to joints, and falling off a bicycle is also dangerous. If the patient has balance issues, weakness, or vision problems, it is better to exercise at home on a stationary bike.

ADVISE THE PATIENTS!:

Do not force yourself to endure severe pain; perform exercises only as far as the emerging pain allows, and stop the exercise immediately if the pain intensifies.

Prevention of exacerbations and training of joint functional capacities

Shoulder joint

• circular arm movements;
• forward and backward swinging movements with lowered arms;
• up and down swinging movements with straight arms;
• raising and lowering the shoulders;
• bringing the shoulders toward the sternum and pulling them back toward the scapulae.

Elbow joint

• flexion and extension of the arms at the elbows;
• arms bent at the elbows in front of the body parallel to each other, rotating first in one direction, then in the other;
• arms lowered, rotating in the joint, turning inward and outward.

Wrist joint

• clenching and unclenching the fingers;
• grasping movements, picking up and holding a small ball with hands;
• circular hand movements in different directions;
• maximum flexion and extension of the hands up and down.

Hip joint

• lying on your back, alternating swinging movements with straight legs upwards;
• lying on your side, lifting the straight leg upwards;
• lying on your back, bend your knees and move your pelvis right and left;
• bend both legs at the knee joints as much as possible without lifting your feet off the floor; in this position, spread your knees apart and bring them back together, trying to gradually increase the range of motion. Repeat 10-15 times.;
• circular motions in the hip joint;
• standing with feet shoulder-width apart, curl and uncurl your toes.

Knee joint

• rolling a stick or a small ball back and forth;

• simulating walking movements with the legs;
• the "bicycle" exercise or exercising on an exercise bike.

As the knee mobility improves, while holding onto a support, you can gradually progress to half-squats and squats.

Exercises performed from the supine position (lying on your back)

• performed with straightened legs. Step one – bend the knee, step two – lift the foot. Hold the bent and lifted leg for a few seconds and lower it. Repeat with the other leg. Repeat several times;
• bend your leg at the knee and pull it toward your abdomen for a few seconds. Lower the leg gradually: first place the foot on the floor, then straighten the leg with a sliding motion;
• perform leg movements simulating bicycle riding. The exercise is performed for several seconds;
• perform a relaxation exercise for the knee joints. To do this, sit on a table or another surface so that your legs dangle without touching the floor. Perform rotational movements in the joints. The range of motion should be increased as pain allows.

Exercises performed from the prone position (lying on your stomach)

• lie down on a mat, keep your legs straight. Lift the straightened leg off the floor and hold it for up to 30 seconds. Ensure that all muscles of the leg and the gluteal muscles are maximally tensed, and your torso is pressed as flat against the floor as possible. Breathe freely. Lower the leg slowly and rest for a moment. Perform the exercise 1-2 times with each leg. You do not need to lift the leg as high as possible;
• perform the same exercise at a faster pace. Hold the leg for 1-2 seconds. Start with at least 8 repetitions. Movements should be smooth. Only in this case does the exercise improve blood circulation;
• bend your leg at the knee at a right angle and lift it off the floor as high as possible. Hold this position for 30 seconds. All movements must be performed with muscular effort of the legs and glutes. The torso is pressed firmly to the floor, do not arch your back. Lower the leg slowly and rest. Repeat with the other leg. Perform 1-2 times;
• perform the previous exercise at a faster pace. Movements should be smooth, with 8 or more repetitions. Take a break of at least 2 seconds between each repetition. Make sure the bent knee remains at a right angle.
• Recommended for patients with good physical conditioning. Lift straightened legs and arms above the floor and hold this position for 30 seconds. Slowly return to the starting position. You can make the exercise more challenging by slowly spreading and bringing the raised legs together. This exercise is not recommended for patients with arterial hypertension or a predisposition to it!

Ankle joint

• sitting, alternately resting your toes and then your heel on the floor;
• sitting, toes on the floor, heel raised, perform circular motions with the heel;
• circular motions of the foot;
• lying down, straight legs together, pull your feet toward you as far as possible;
• perform the same movement using only the toes.

Recommendations for patients after joint replacement surgery

1. The main recommendations for patients who have undergone total knee arthroplasty involve regular home physical therapy to improve the function of the operated joint, the condition of the lower extremity muscles, weight-bearing capacity, restoration of gait pattern and activities of daily living, as well as reducing the risk of falls. Crutches become unnecessary 3-4 weeks after surgery, as soon as the patient's condition allows. Continue using a single crutch until the patient stops limping; the crutch should be held on the side of the healthy leg.
2. The operated leg should be wrapped with an elastic bandage for up to 3 months postoperatively. Patients must monitor their health, as exacerbations of chronic diseases, acute infections, hypothermia, or overfatigue can lead to inflammation of the operated joint. If body temperature rises, the operated joint swells, the skin over it becomes red, or joint pain increases, the patient must consult a doctor immediately.
3. Hazardous activities after surgery: running, jumping, ball games, contact sports, and aerobics are not recommended. Activities exceeding normal postoperative recommendations: excessively long or tiring walks, tennis, lifting weights over 25 kg. Permitted activities after surgery: gentle walks, swimming, golf, driving, "non-extreme" tourism, ballroom dancing, climbing low stairs, skiing, cycling, Nordic walking. If the operated knee begins to ache and swell after exertion, activity levels should be temporarily reduced.
4. It is recommended to wear low-heeled shoes, temporarily remove loose rugs and cords, and gradually increase walking duration and weight-bearing on the operated leg. When walking, patients should try to keep their back straight, look forward, and place the foot directly in front or slightly to the side, bending the knee when the foot is in the air and straightening it when the foot bears weight on the floor. In winter, when walking on slippery surfaces, patients should use anti-slip attachments for footwear and crutches.
5. When getting into a car, it is advisable for the patient to sit in the front passenger seat after reclining the backrest and pushing the seat as far back as possible. Enter the car by leaning on crutches or another sturdy support. When getting in, lean your upper body back and transfer your legs, controlling their movement. During the ride, the patient should sit in a comfortable position, leaning against the seat back. Driving is permitted when the patient can easily get into the car and control pedal pressure. Most often, this occurs 4–6 weeks after surgery. Driving earlier than this period is only permitted if the vehicle has an automatic transmission.
6. After surgery, patients must follow these rules: ensure that the surface they sit on is no lower than knee height; avoid abrupt movements when standing up and sitting down; do not sit for longer than 15-20 minutes and do not stand in one place for longer than 30 minutes; after walks, lie on your back and keep your legs elevated for at least 30 minutes; place a pillow between your knees during rest and avoid joint hyperextension. Avoid: excessive inward or outward rotation of the legs, rotational leg movements, sharp sideways swings; lifting, carrying, and pushing heavy objects (over 10 kg); weight gain; falls and jolts; deep squats; jumping; sudden movements and braking; prolonged sitting with crossed legs.
7. It is best for patients to rest lying on their back 3-4 times a day. During rest, you may lie on your side, but use a bolster or pillow between your thighs. Avoid sleeping on too soft or low a bed; ideally, it should be higher than knee level (when the patient is standing).
8. Keep in mind that metal detectors may react to the patient's joint prosthesis.
9. For the first 6 weeks after surgery, it is advisable to avoid taking hot baths and instead take warm showers. Visiting baths or saunas is strictly prohibited during the first 1.5 to 3 months.
10. Patients must undergo annual follow-up imaging and visit the clinic for a consultation.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

APPENDIX G1 Visual Analogue Scale for pain intensity

Russian name: Visual Analog Scale for Pain Intensity

Original name: Visual analogue scale

Source: Price D. D., McGrath P. A., Rafii A., Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain// Pain: September 1983 - Volume 17 - Issue 1 - p 45-56, doi: 10.1016/0304-3959(83)90126-4

Type (underline):

• rating scale
• index
• questionnaire
• other

Purpose: assessment of pain intensity

Content (template):

The patient is asked to mark a point on a 10 cm ungraduated line that corresponds to the severity of pain. The reverse side of the ruler has centimeter markings, which the physician uses to record the obtained value.

Key (interpretation):

The left boundary of the line corresponds to the definition "no pain", and the right boundary corresponds to "the worst pain imaginable".

APPENDIX G2 Numeric Rating Scale for pain

Russian title: Numerical Rating Scale for pain

Original name: Numeric Rating Scale

Source: Bijur, P.E., Latimer, C.T. and Gallagher, E.J. (2003), Validation of a Verbally Administered Numerical Rating Scale of Acute Pain for Use in the Emergency Department. Academic Emergency Medicine, 10: 390-392. doi:10.1111/j.1553-2712.2003.tb01355.x

Type (underline):

• rating scale
• index
• questionnaire
• other

Purpose: assessment of pain intensity

Content (template):

The scale consists of a sequential series of numbers from 0 to 10. Patients are asked to rate pain intensity using numbers: 0 – no pain, 5 – moderate pain, and 10 – the worst pain imaginable.

Key (interpretation):

APPENDIX G3 Faces Pain Scale (FPS)

Russian name: Faces Pain Scale

Original name: Faces Pain Scale

Source: Fadayevatan R, Alizadeh-Khoei M, Hessami-Azar ST, Sharifi F, Haghi M, Kaboudi B. Validity and Reliability of 11-face Faces Pain Scale in the Iranian Elderly Community with Chronic Pain. Indian J Palliat Care. 2019;25(1):46–51. doi:10.4103/IJPC.IJPC_126_18

Type (underline):

• rating scale
• index
• questionnaire
• other

Purpose: assessment of pain intensity

Content (template):

The patient is presented with an image of 11 faces. The patient chooses the face that best corresponds to their condition.

Key (interpretation):

The patient is presented with an image of 11 faces. The first face from left to right is calm and happy, corresponding to the absence of pain; the last face expresses very severe pain.

APPENDIX G4 Scale for assessing chronic pain intensity in patients with dementia

Russian name: Pain Assessment Scale in Advanced Dementia

Original title: Pain Assessment In Advanced Dementia

Source: Warden V, Hurley AC, Volicer L. Development and Psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. Journal of the American Medical Directors Association. 2003;4:9–15. doi: 10.1016/S1525-8610(04)70258-3.

Type (underline):

• rating scale
• index
• questionnaire
• other

Purpose: assessment of pain in advanced dementia

Content (template):

The scale represents a set of criteria evaluated by a medical professional based on severity when relatives report patient deterioration, but the patient cannot communicate it independently.

Key (interpretation):

• 1 – 3 points – mild pain
• 4 – 6 points – moderate pain
• 7 – 10 points – severe pain

APPENDIX G5 «Age Is No Obstacle» questionnaire

Russian title: "Age is No Obstacle" questionnaire

Original title: "Age is No Obstacle" questionnaire

Source: O. N. Tkacheva, N. K. Runikhina, V. S. Ostapenko, N. V. Sharashkina,

E. A. Mkhitaryan, Yu. S. Onuchina, S. N. Lysenkov. Validation of the screening questionnaire for frailty syndrome in outpatient practice // USPEKHI GERONTOLOGII, 2017, Vol. 30, No. 2, pp. 236-242

Type (underline):

• rating scale
• index
• questionnaire
• other

Purpose: screening for frailty syndrome

Content (template):

The "Age is No Obstacle" questionnaire was developed and validated for frailty screening. It includes 7 questions regarding weight loss, sensory deficits, falls, symptoms of depression and cognitive impairment, urinary incontinence, and decreased mobility. The questionnaire can be completed by a nurse or non-medical personnel (e.g., volunteers), as well as by the patient themselves. For each positive answer, the patient scores 1 point, and for a negative answer, 0 points. The maximum possible score on the questionnaire is seven.

* This refers to unintentional weight loss. If the patient lost weight intentionally — through a special diet or regular physical activity, no point is awarded. 1 point is awarded for each positive answer.

Key (interpretation):

• 1 – 2 points – frailty is absent
• 3 – 4 points – pre-frailty
• 5 points or more – probable frailty

APPENDIX G6 DN4 neuropathic pain diagnostic questionnaire

Russian title: DN4 neuropathic pain diagnostic questionnaire

Original title: Douleur Neuropathique en 4 Questions

Source: Bouhassira D., Attal N., Alchaar H., Boureau F., Brochet B., Bruxelle J., Cunin G., Fermanian J., Ginies P., Grun-Overdyking A., Jafari-Schluep H., Lantéri-Minet M., Laurent B., Mick G., Serrie A., Valade D., Vicaut E. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4) // Pain: March 2005 - Volume 114 - Issue 1 - p 29-36 doi: 10.1016/j.pain.2004.12.010

Type (underline):

• rating scale
• index
• questionnaire
• other

Purpose: identification of neuropathic pain or the neuropathic component of pain in mixed nociceptive-neuropathic pain syndromes

Content (template):

The questionnaire consists of two sections. The first is completed based on the patient interview, and the second based on the clinical examination. The first section evaluates positive sensory symptoms, while the second section identifies allodynia and negative sensory symptoms

Key (interpretation):

If the total score is 4 or more, it indicates that the patient's pain is neuropathic, or that there is a neuropathic component of pain (in mixed nociceptive-neuropathic pain syndromes).

APPENDIX G7 PainDETECT questionnaire

Russian title: PainDETECT questionnaire

Original title: PainDETECT questionnaire

Source: R. Freynhagen, R. Baron, U. Gockel, T. R. Tölle (2006) painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain // Current Medical Research and Opinion, 22:10, 1911-1920, DOI: 10.1185/030079906X132488

Type (underline):

• rating scale
• index
• questionnaire
• other

Purpose: assessment of the pain course pattern and diagnosis of the neuropathic pain component

Content (template):

The questionnaire is intended to be completed by the physician and combines a pain distribution diagram with a VAS scale and a questionnaire aimed at identifying spontaneous and evoked symptoms of neuropathic pain. The diagram is also used to assess the pattern of pain progression: continuous, paroxysmal, continuous with exacerbations, etc. The questionnaire comprehensively reflects all possible pain parameters and provides a very clear visual tracking of the pain syndrome dynamics over time.

Key (interpretation):

A score of 19 points and above indicates the presence of a pronounced neuropathic component

APPENDIX G8 Questions for a comprehensive assessment of pain syndrome in patients over 60 years of age (approximate list)

Russian title: Questions for comprehensive pain assessment in patients over 60 years of age

Original title: Elements of a comprehensive geriatric pain assessment

Source: Royal College of Physicians, British Geriatrics Society, and British Pain Society. The assessment of pain in older people: national guidelines. Concise guidance to good practice series, No 8. Royal College of Physicians, Oct 2007.; American Geriatrics Society Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002;50(Suppl 6):205-24.

Type (underline):

• rating scale
• index
• questionnaire
• other

Purpose: Comprehensive assessment of the nature and course of pain in patients over 60 years of age

Content (template):

The physician asks the patient the following questions and, based on the answers, draws a conclusion about the nature and course of the pain syndrome.

General questions

1. Please indicate all the areas where you experience pain or discomfort. What does your pain feel like? What words come to mind?
2. What is the intensity of your pain now (current / average over the past week)?
3. Is your pain constant or does it bother you from time to time?
4. What increases the intensity of the pain?
5. How often over the past week have you taken pain relievers?

Assessment of the impact of pain on functional status

1. How many days over the past week were you unable to do what you would like to do because of pain?
2. How often over the past week did pain interfere with your ability to care for yourself, such as bathing, eating, dressing, and using the toilet?
3. How often over the past week did pain interfere with managing your household chores, such as grocery shopping, cooking, paying bills, and driving a car?
4. How often do you engage in your hobbies, socialize with friends, travel? How often over the past week did pain interfere with these activities?
5. How often do you exercise? How often over the past week did pain interfere with your workouts?

Assessment of the impact of pain on mental status

1. Does the pain affect your energy levels, mood, personality traits, or relationships with other people?
2. Are you worried about your pain?
3. What do you think might be the cause of your pain?
4. Does the pain affect your ability to think clearly?
5. What do you do to help cope with the pain? (listen to your favorite music, pray, sit quietly, or try to isolate yourself)
6. How would you rate your current health? (excellent, good, fair, poor, or very poor)

Assessment of the impact of pain on physical status

1. Does the pain affect your appetite? Have you lost weight?
2. Does the pain affect your nighttime sleep? How often over the past week have you been awake due to pain?
3. Do you have trouble falling asleep or do you need to take medication to fall asleep because of your pain?
4. When you feel pain, does your blood pressure or blood sugar rise, or do you experience heart pain? (other wording if appropriate comorbid conditions are present)

Assessment of patient attitudes and beliefs about pain

1. Do you have any thoughts or opinions as to why you are experiencing pain at this time that you think it would be important for me to know?
2. Do you have any thoughts or opinions on specific pain management methods that you feel would be important for me to know?

Assessment of external support resources

1. Is there anyone at home or in the community whom you can turn to for help and support when your pain is severe?

Treatment expectations and goals

1. What do you think might happen to you during the course of treatment that I have recommended?
2. What are the most important things that will change after we treat your pain?

Key (interpretation):

Clinical analysis of the submitted responses

APPENDIX G9

Russian title: Mini-Mental State Examination
Original title: Mini Mental State Examination (MMSE)

Source: Folstein M. et al. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. // J Psychiatr Res 1975; 12:189-98.

Type (underline):
-rating scale
-index
-questionnaire
-other

Purpose: initial assessment of cognitive functions and screening for impairments

Content (template):

The patient is asked to answer questions, and the completeness and correctness of the answer are scored in points.

*
   

The total score is calculated by summing the results of each item

Key: The maximum score on this test is 30 points, which corresponds to an optimal state of cognitive function. The lower the total score, the more pronounced the cognitive deficit.

28 – 30 points – no cognitive impairment;

24 – 27 points – pre-dementia cognitive impairment;

20 – 23 points – mild dementia;

11 – 19 points – moderate dementia;

0 – 10 points – severe dementia.

APPENDIX G10 Diagnostic criteria for osteoarthritis (knee, hip, and hand joints)

Russian title: Diagnostic criteria for osteoarthritis

Original title: -

Source: Altman RD, Block DA, Brandt KD, Cooke DV, Greenwald RA, Hochberg MC, Howell DS, Ike RW, Kaplan D, Koopman W. Osteoarthritis: definitions and criteria. Ann Rheum Dis. 1990 Mar;49(3):201. doi: 10.1136/ard.49.3.201-a. PMID: 2353984; PMCID: PMC1004025. Type (underline):

• rating scale
• index
• questionnaire
• other (diagnostic criteria)

Purpose: diagnosis of osteoarthritis

Content (template):

Classification diagnostic criteria imply the presence of pain syndrome in the affected joint and other signs presented below.

Key (interpretation): (specified above)

APPENDIX G11 SARC-F questionnaire for sarcopenia screening

Russian name: SARC-F questionnaire

Original name: Sarcopenia Fast

Source: Cruz-Jentoft A.J. et al. Sarcopenia: revised European consensus on definition and diagnosis // Age and ageing.-2018.

Type (underline):
-rating scale
-index
-questionnaire
-other: test

Purpose: sarcopenia screening

Content (template): A list of questions with response options, each carrying a different point score. The probability of sarcopenia in a patient is determined by the total score.

Key (interpretation):

0-3 points: no sarcopenia

>4 points: probable sarcopenia

APPENDIX G12 Confusion Assessment Method for the ICU (CAM-ICU)

Russian name: Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), delirium diagnostic algorithm

Original name: CAM-ICU, Confusion Assessment Method-Intensive Care Unit

Source: Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Bernard GR, Inouye SK. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2001 Jul;29(7):1370-9. doi: 10.1097/00003246-200107000-00012. PMID: 11445689.

Type (underline):
-scale
-index
-questionnaire
-other: assessment method

Purpose: delirium screening

Content (template): A list of consecutive questions used to determine further management: either proceeding to the next question or providing a conclusion on the presence of delirium.

1. Acute onset or fluctuating course of mental status changes

· Are there any changes in mental status compared to the baseline level?

OR

· Were there fluctuating changes in mental status over the past 24 hours?

Test results: if the answers to the questions are NO, then the CAM-ICU is negative, i.e., no delirium.
If the answer is YES, proceed to the next step.

IF YES

2. Inattention

· Letter test: "Squeeze my hand every time I say the letter A." Read the letters from the following list: A B R A C A D A B R A (pronounce the letters individually with a 3-second pause). An error is counted if the patient does not squeeze the hand on the letter "A" or squeezes the hand on any letter other than "A".

OR

· Perform a visual picture test

Test results:
If there are 0–2 errors during testing, the CAM-ICU is negative, i.e., no delirium. If there are more than 2 errors, proceed to the next step.

IF MORE THAN 2 ERRORS

3. Altered level of consciousness

· Determine the current level of consciousness using the RASS scale.

Test results:
If RASS is other than 0, the CAM-ICU is positive, i.e., delirium is present. If RASS is 0, proceed to the next step.

            RASS is 0

4. Disorganized thinking

· YES / NO questions

1. Will the stone float on water?
2. Does a fish live in the sea?
3. Does one kilogram weigh more than two?
4. Can you drive a nail with a hammer?

· Commands: tell the patient:

1. "Show this many fingers" (hold up 2 fingers in front of the patient).
2. "Now do the same with the other hand" (do not repeat the number of fingers).

If the patient cannot move both hands, for the second part of the command ask the patient: "Add one more finger."

Test results:
If 0–1 error, CAM-ICU is negative, i.e., no delirium. If more than 1 error, CAM-ICU is positive, i.e., delirium is present.