Ponencia invitada en la V Jornada de Fisioterapia en Geriatría, Barcelona 2015. "Pain management in the elderly". Invited speaker at V Jornada de Fisioterapia en Geriatría, Barcelona 2015.

1. Eva Sierra Silvestre
@esiesil

2. DOLOR

3. 73.5%
Miró, J., Paredes, S., Rull, M., Queral, R., Miralles, R., Nieto, R., … & Baos, J. (2007). Pain in older adults: A prevalence study in the Mediterranean region of Catalonia.
European Journal of Pain, 11: 83. doi: 10.1016/j.ejpain.2006.01.001
DOLOR
CRÓNICO
94.5%

4. Bonifazi, W.L. (2000). Painful truths. Contemporary Long Term Care, 23(8), 1
No se diagnostica
No se trata
Se confunde con
demencia o depresión
Frecuentemente, el dolor…

5. ¿QUÉ TIENE DE
ESPECIAL EL
DOLOR
EN LOS
MAYORES?

6. Mielinizadas: 35%
No mielinizadas: 50%
[Neurotransmisores]
Transporte axonal
AFERENTES NOCICEPTIVAS PRIMARIAS
Verdu E, Ceballos D, Vilches JJ, et al. Influence of aging on peripheral nerve function and regeneration. J Peripher Nerv Syst. 2000;5:191–208.
Ochoa J, Mair WGP. The normal sural nerve in man. II. Changes in the axon and schwann cells due to ageing. Acta Neuropathol (Berl). 1969; 13:217–239.
O’Sullivan DJ, Swallow M. The fibre size and content of the radial and sural nerves. J Neurol Neurosurg Psychiatry. 1968;31:464–470.
Rafalowska J, Drac H, Roeinska K. Histological and electrophysiological changes of the lower motor neuron with aging. Polish Medical Science and Histology Bulletin.
1976;15:271–280

7. SISTEMA NERVIOSO CENTRAL
Muerte
neuronal
Pérdida de las
ramificaciones
dendríticas
Cambios
neuroquímicos
Pérdida de
mielina
Deterioro
sistema
inhibidor endógeno
del dolor
Prineas JW, Spencer PS. Pathology of the nerve cell body in disorders of the peripheral nervous system. In: Dyck PJ, Thomas PK, Lambert EH, eds. Peripheral Neuropathy.
Philadelphia: W B Saunders; 1975:253–295.
Ko ML, King MA, Gordon TL, et al. The effects of aging on spinal neurochemistry in the rat. Brain Res Bull. 1997;42:95–98.
Hamm RJ, Knisely JS. Environmentally-induced analgesia: an agerelated decline in a neurally-mediated, nonopioid system. Psychol Aging. 1986;1:195–201.
Bodnar RJ, Romero MT, Kramer E. Organismic variables and pain inhibition: roles of gender and aging. Brain Res Bull. 1988;21:947–953.

8. UMBRALES DE DOLOR
Umbral
estímulos térmicos
Umbral
dolor a la presión
Lautenbacher, S., Kunz, M., Strate, P., Nielsen, J., & Arendt-Nielsen, L. (2005). Age effects on pain thresholds, temporal summation and spatial summation of heat and
pressure pain. Pain, 115(3), 410–8. doi:10.1016/j.pain.2005.03.025
Tolerancia
Al dolor

9. DETERIORO COGNITIVO
Respuesta a
estímulos limitada
Expresividad facial
Conductas de dolor
Scherder E, Bouma A, Borkent M, Rahman O. Alzheimer patients report less pain intensity and pain affect than non-demented elderly. Psychiatry [Internet].
1999;62(3):265–72
Scherder E J, Sergeant J A, Swaab D F et al. Pain processing in dementia and its relation to neuropathology. Lancet Neurology 2003; 2:677–686

10. ¿DE QUÉ TIPOS DE
DOLOR
HABLAMOS?

11. DOLOR
AGUDO
Gibson, S. J., & Helme, R. D. (2001). Age-related differences in pain perception and report. Clinics in Geriatric Medicine, 17(3), 433 456.
Tresch, D. D. (1998). Management of the older patient with acute myocardial infarction: difference in clinical presentations between older
and younger patients. Journal of the American Geriatrics Society, 46,1157 1162.
Enfermedades
que cursan
con dolor
Confusión
Agitación
Agresividad
Anorexia
Fatiga
¿Dolor?

12. DOLOR
AGUDO
Cole, L. J., Farrell, M. J., Gibson, S. J., & Egan, G. F. (2010). Age-related differences in pain sensitivity and regional brain activity evoked by
noxious pressure. Neurobiology of Aging, 31(3), 494 503
Gibson S. J. In: Proceedings of the 10th World Congress on Pain, Progress in Pain Research and Management. Vol. 24. Dostrovsky J. O.,
Dolor bien
localizado
Localización
atípica
Intensidad
dolor
decreciente
con la edad

13. Lynch D. Geriatric pain. In: Raj P. P., editor. Practical Management of Pain. 3rd ed. St. Louis, MO: Mosby; 2000. pp. 270–271
DOLOR CRÓNICO

14. Trombosis venosa
profunda
Fracturas
Tromboembolismo
pulmonar
Rastogi, R., & Meek, B. D. (2013). Management of chronic pain in elderly, frail patients: finding a suitable, personalized method of control. Clinical Interventions in Aging, 8, 37–46
Baja calidad de
vida
COMORBILIDAD
DOLOR CRÓNICO

15. Kaye, A. D., Baluch, A., & Scott, J. T. (2010). Pain management in the elderly population: a review. The Ochsner Journal, 10(3), 179–87.

16. Miró, J., Paredes, S., Rull, M., Queral, R., Miralles, R., Nieto, R., Huguet, A. and Baos, J. (2007), Pain in older adults: A prevalence study in the Mediterranean region of
Catalonia. European Journal of Pain, 11: 83. doi: 10.1016/j.ejpain.2006.01.001
Fisioterapia
TRATAMIENTO

17. ¿QUÉ HAY DE
NUEVO EN
FISIOTERAPIA?

18. ARTROSIS
Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database of
Systematic Reviews 2015, Issue 1. Art. No.: CD004376. DOI: 10.1002/14651858.CD004376.pub3
Lluch Girbés, E., Nijs, J., Torres-Cueco, R., & López Cubas, C. (2013). Pain treatment for patients with osteoarthritis and central sensitization.
Physical Therapy, 93(6), 842–51

19. ARTROSIS
Nijs, J., Paul van Wilgen, C., Van Oosterwijck, J., van Ittersum, M., & Meeus, M. (2011). How to explain central sensitization to patients with “unexplained” chronic
musculoskeletal pain: practice guidelines. Manual Therapy, 16(5), 413–8.
Lluch Girbés, E., Nijs, J., Torres-Cueco, R., & López Cubas, C. (2013). Pain treatment for patients with osteoarthritis and central sensitization. Physical Therapy, 93(6), 842–51

20. ARTROSIS
Hurley MV, Walsh NE, Mitchell H, Nicholas J, Patel A. Longterm outcomes and costs of an integrated rehabilitation program for chronic knee pain: a pragmatic, cluster
randomized, controlled trial. Arthritis Care Res 2012;64:238e47.

21. Waller, B., Ogonowska-Slodownik, A., Vitor, M., Lambeck, J., Daly, D., Kujala, U. M., & Heinonen, A. (2014). Effect of therapeutic aquatic
exercise on symptoms and function associated with lower limb osteoarthritis: systematic review with meta-analysis. Physical Therapy,
ARTROSIS

22. Avelar NC, Simao AP, Tossige-Gomes R, Neves CD, RochaVieira E, Coimbra CC, et al. The effect of adding whole-body vibration to squat training on the functional performance
and self-report of disease status in elderly patients with knee osteoarthritis: a randomized, controlled clinical study. J Altern Complement Med 2011;17:1149e55
Fukuda TY, Alves da Cunha R, Fukuda VO, Rienzo FA, Cazarini Jr C, Carvalho Nde A, et al. Pulsed shortwave treatment in women with knee osteoarthritis: a multicenter,
randomized, placebo-controlled clinical trial. Phys Ther 2011;91:1009e17.
ARTROSIS

23. NEUROPATÍA DIABÉTICA
Boyd, B. S., Wanek, L., Gray, A. T., & Topp, K. S. (2010). Mechanosensitivity during lower extremity neurodynamic testing is diminished in individuals with Type 2 Diabetes
Mellitus and peripheral neuropathy: a cross sectional study. BMC Neurology, 10, 75. doi:10.1186/1471-2377-10-75
Kumar P.S., Adhikari P., Jeganathan P.S, D’Souza S.C. Immediate effects of nerve sliders and nerve massage on vibration and thermal perception thresholds in patients with

24. DOLOR POR CÁNCER
Bernabei R, Gambassi G, Lapane K, et al. Management of Pain in Elderly Patients With Cancer. JAMA. 1998;279(23):1877-1882.
McNeely ML, Campbell K, Ospina M, Rowe BH, Dabbs K, Klassen TP, Mackey J, Courneya K. Exercise interventions for upper-limb dysfunction due to breast cancer treatment.
Cochrane Database of Systematic Reviews 2010, Issue 6. Art. No.: CD005211.
Fong Daniel Y T, Ho Judy W C, Hui Bryant P H, LeeAntoinette M, Macfarlane Duncan J, Leung Sharron S K et al. Physical activity for cancer survivors: meta-analysis of randomised
controlled trials BMJ2012; 344 :e70

25. RESUMIENDO…
Makris, U. E., Abrams, R. C., Gurland, B., & Reid, M. C. (2014). Management of persistent pain in the older patient: a clinical review. JAMA, 312(8), 825–36.
doi:10.1001/jama.2014.9405

26. ¡Envejezcamos juntos!
Lo mejor está por llegar
-Robert Browning-

27. Eva Sierra Silvestre
eva.sierra.silvestre@gmail.com
@esiesil

28. Imágenes
• Portada: http://images.wisegeek.com/elderly-womans-hands.jpg
• Nº2: http://www.haddenham.net/med/elderly-man-M80903.jpg
• http://downtownlalaw.com/wp-content/uploads/2012/08/Elderly-Nursing-Home-Abuse-Laws-
California.jpg
• http://www.thoughtpursuits.com/wp-content/uploads/2014/05/an-old-woman4.jpg
• http://media3.popsugar-
assets.com/files/2014/02/28/037/n/1922441/e92047784e279033_thumb_temp_image14898002
1393627278.jpg.xlarge/i/45-Life-Lessons-Written-90-Year-Old-Woman.jpg
• http://www.neon.org.nz/images/Aged%20care%20Inquiry/_43Y9482-cropped.jpg
• Nº3: http://s.icons8.com/wp-content/uploads/2014/11/old_woman.png
• http://s.icons8.com/wp-content/uploads/2014/11/old_man.png
• Nº4: http://www.innovage.group.shef.ac.uk/assets/files/Innovage%20News%201%20(web).pdf
• Nº5: http://safetyfirstfinancialplanners.com/wp-content/uploads/2014/02/oldmanMedium.jpg
• Nº6:http://comps.canstockphoto.es/can-stock-photo_csp3855629.jpg
• Nº7:http://funderstanding.com/wp-content/uploads/2011/04/brain-based-learning.png
• Nº8: https://lh3.googleusercontent.com/3e_3aQtfwwRnN4m-
ZRi5ntSUbvUvVth0TShbUQAl_HxeKSus2oI5CNi2zICfxDU9MD3pbf4=s121
• Nº9:http://www.centropsicologicocpc.es/wp-content/uploads/2014/12/deterioro-cognitivo1.jpg
• Nº11: http://www.geneticportraits.ca/
• Nº13: http://blogs.discovermagazine.com/d-brief/files/2013/03/shutterstock_89553295.jpg

29. Imágenes
• Nº15:http://bottomlessmimosa.com/wp-content/uploads/homeless-man1.png
• Nº16: http://img.freepik.com/fotos-gratis/personagens-de-desenhos-animados-medicos_23-
2147498614.jpg?size=318cf&ext=jpg
• https://s-media-cache-ak0.pinimg.com/236x/23/39/df/2339df6df8eefaf5f2cf55b15cfd3f80.jpg
• http://www.freepik.es/vector-gratis/ejercita-tu-cerebro_771734.htm
• Nº17:
http://4.bp.blogspot.com/_WiqMAWNl9Js/TI4QwPMra4I/AAAAAAAAIdM/2bjDjmd5Qk8/s320/fisio
terapia+cl%C3%A1sica+marcha+paralelas.jpg
• Nº18:http://ys.fh21.com.cn/uploads/allimg/150127/12_150127133629_1.jpg
• Nº19:http://whatwillmatter.com/wp-content/uploads/2012/06/Education-brain-as-a-
muscle_68644981.jpg
• Nº20: https://ufhealth.org/sites/default/files/media/News/COM/LIFE%20Study_JSJ_IMG_1477.jpg
• Nº21:
http://mediad.publicbroadcasting.net/p/shared/npr/styles/x_large/nprshared/201307/205474633.
jpg
• Nº22:http://www.diariohoracero.com/images/familia_45_03.jpg
• https://www.fisiomarket.com/2067-home_default/Onda-Corta-INTELECT-SHORTWAVE-400.jpg
• Nº23:http://free-stock-illustration.com/abdominal+exercises+for+seniors?image=37495902
• Nº24:http://i.telegraph.co.uk/multimedia/archive/02432/elderly-cancer_2432803k.jpg
• Nº25:http://3.bp.blogspot.com/-4JcV8HpSQBg/TqDXmq3qHzI/AAAAAAAAUAs/y-
6hgac2zEI/s400/vejez%252Btomados%2Bde%2Bla%2Bmano.jpg
• Nº26: http://stevemccurry.com/blog/stronger-weakness
• Nº27:https://farm8.staticflickr.com/7360/13379246975_a0168daf45_b.jpg